Life Works Self-Assesment - Hill Country Family Services

1 (In Crisis) 2 (Vulnerable) 3 (Safe) 4 (Building Capacity) 5 (Empowered)

Name(Required)

First Last

Housing(Required)

(In crisis) Homeless or threatened with eviction

(Vulnerable) In transitional, temporary, or substandard housing OR current rent/mortgage payment is unaffordable (over 30% of income)

(Safe) In stable housing that is only marginally adequate.

(Building Capacity) Household is in adequate, subsidized housing.

(Empowered) Household is in adequate, unsubsidized housing.

Don't Know

Not Applicable

Employment(Required)

(In crisis) No Job

(Vulnerable) Temporary, part-time, or seasonal job; inadequate pay and no benefits.

(Safe) Employed full-time; inadequate pay; few or no benefits.

(Building Capacity) Employed full-time with adequate pay and benefits.

(Empowered) Maintains permanent full- time employment with adequate pay and benefits.

Don't Know

Not Applicable

Income(Required)

(In crisis) No income.

(Vulnerable) Inadequate income OR spontaneous/inappropriate spending.

(Safe) Can meet basic needs with subsidy.

(Building Capacity) Can meet basic needs without assistance.

(Empowered) Income is sufficient and well-managed; has discretionary income and is able to save.

Don't Know

Not Applicable

Food(Required)

(In crisis) No food or means to prepare it. Relies significantly on other sources of free or low-cost food.

(Vulnerable) Household is on SNAP or relies on some other type of assistance.

(Safe) Can meet basic food needs but requires occasional assistance.

(Building Capacity) Can meet basic food needs without assistance.

(Empowered) Income Can choose to purchase any food the household desires.

Don't Know

Not Applicable

Healthcare Coverage(Required)

(In crisis) At least one household member has immediate need for medical care or attention and has no medical coverage.

(Vulnerable) No immediate need, but at least one household member has no medical coverage and great difficulty accessing medical care when needed.

(Safe) At least one household member has no immediate need and no medical coverage, but is able to access medical care when neede

(Building Capacity) All household members have some type of medical coverage, but it may strain budget or is less than adequate.

(Empowered) All household members are covered by affordable, adequate health insurance.

Don't Know

Not applicable

Adult Education(Required)

(In crisis) No HS diploma/GED and is not enrolled in high school or a GED program.

(Vulnerable) No HS diploma/GED, but the client is enrolled in high school or a GED program.

(Safe) Client has HS diploma/GED but is not seeking additional education/training to benefit employment.

(Building Capacity) Client has HS diploma/GED and is seeking additional education/training to benefit employment.

(Empowered) Client has completed additional education/ training beyond HS diploma/GED (and is in a position where he/she is employable).

Don't Know

Not Applicable

Language/ Literacy(Required)

(In crisis) Literacy or language problems are serious, unaddressed barriers to employment or accomplishing basic day-to-day tasks.

(Vulnerable)Client has serious language or literacy issues but is enrolled in a literacy or language program.

(Safe) Client has a sufficient command of English to where language or literacy is not a barrier to employment or accomplishing basic day-to-day tasks.

(Building Capacity) Client has sufficient command of English but is seeking additional education to resolve remaining language or literacy problems.

(Empowered) Client has no language or literacy problems.

Don't Know

Not Applicable

Mobility(Required)

(In crisis) No access to transportation (public or private).

(Vulnerable) Transportation is available but unreliable, unpredictable, or unaffordable.

(Safe) Transportation is available and reliable, but inconvenient.

(Building Capacity) Transportation is readily available and convenient but not preferred; if client owns a car, lacks either a driver’s license or insurance.

(Empowered) Transportation is readily available, affordable, and satisfactory; if client owns a car, has driver’s license and a car that is adequately insured.

Don't Know

Not Applicable

Disabilities & Physical Health(Required)

(In crisis) Acute or chronic symptoms are currently affecting housing, employment, social interactions, etc.

(Vulnerable) Sometimes or periodically has acute or chronic symptoms affecting housing, employment, social interactions, etc.

(Safe) Rarely has acute or chronic symptoms affecting housing, employment, social interactions, etc.

(Building Capacity) Asymptomatic; condition is controlled by services or medication.

(Empowered) No identified disability or health concerns.

Don't Know

Not Applicable

Mental Health(Required)

(In crisis) Danger to self or others; recurring suicidal thoughts; experiencing severe difficulties in day-to-day life due to psychological issues.

(Vulnerable) Recurrent mental health symptoms that may affect behavior but not a danger to self/others; persistent issues with functioning due to mental health symptoms.

(Safe) Mild symptoms may be present but are transient; only moderate difficulty in functioning due to mental health issues.

(Building Capacity) Minimal symptoms that are expectable responses to life stressors; only slight impairment in functioning.

(Empowered) Symptoms are absent or rare; good or superior functioning in wide range of activities; no more than everyday problems and concerns.

Don't Know

Not Applicable

Substance Use(Required)

(In crisis) Problems so severe that institutionalized living or hospitalization may be necessary.

(Vulnerable) You have used recreational or prescription drugs in the last 6 months. Have anyone suggested you take a treatment

(Safe) Use within last 6 months, evidence of persistent or recurrent social, occupational, emotional, or physical problems related to use (such as disruptive behavior or housing problems); problems have persisted for at least one month.

(Building Capacity) Client has used substances during the last 6 months, but no evidence of persistent or recurrent social, occupational, emotional, or physical problems related to use, no evidence of recurrent dangerous use.

(Empowered) No drug use/alcohol abuse in the last six months.

Don't Know

Not Applicable

Legal(Required)

(In crisis) Current outstanding tickets or warrants OR currently incarcerated.

(Vulnerable) Current charges/trial pending OR non- compliance with probation/parole.

(Safe) Fully compliant with probation/ parole terms with no charges pending.

(Building Capacity) Has successfully completed probation/parole within the last 12 mo; no new charges filed OR no active criminal justice involvement in more than 12 mo., but prior arrests pose problem to current self-sufficiency.

(Empowered) No criminal history OR no active criminal justice involvement in more than 12 mo, and prior arrests do not pose a problem to current self-sufficiency.

Don't Know

Not Applicable

Safety(Required)

(In crisis) Environment is not safe; immediate level of lethality is extremely high; possible CPS or police involvement.

(Vulnerable) Safety is threatened, but temporary protection is available; level of lethality is high.

(Safe) Current level of safety is minimally adequate; ongoing safety planning is essential.

(Building Capacity) Environment is safe, but future safety is uncertain; safety planning is important.

(Empowered) Environment is apparently safe and stable.

Don't Know

Not Applicable

Credit(Required)

(In crisis) History of bankruptcies, foreclosures, evictions, or repossessions.

(Vulnerable) Outstanding judgments, garnishments, or debts in collection.

(Safe) Has an unmanageable debt ratio and poor credit, OR has no credit history.

(Building Capacity) Has an unmanageable debt ratio or poor credit.

(Empowered) Has a manageable debt ratio and good credit.

Don't Know

Not Applicable

Life Skills(Required)

(In crisis) Unable to complete any of the following life skills without assistance: looking up information online, scheduling appts, prioritizing tasks, arriving on time, and completing tasks on time.

(Vulnerable) Able to complete one or two of these life skills without assistance.

(Safe) Able to complete three of these life skills without assistance.

(Building Capacity) Able to complete four of these life skills without assistance.

(Empowered) Able to complete all five of these life skills without assistance.

Don't Know

Not Applicable

Community Involvement(Required)

(In crisis) Not applicable due to crisis situation; in “survival” mode.

(Vulnerable) Socially isolated, lacks social skills, or unmotivated/does not desire to become involved.

(Safe) Has adequate social skills and motivation/desire but lacks the opportunity or knowledge of ways to become involved.

(Building Capacity) Some community involvement (advisory group, support group, church, volunteering, etc.), but has barriers (transportation, childcare issues, etc.).

(Empowered) Actively involved in community.

Don't Know

Not Applicable

Network Support(Required)

(In crisis) Extended family or friends are uninvolved, uninterested, or unmotivated to provide support.

(Vulnerable) Extended family/friends lack the ability or resources to help (either financially, emotionally, or materially) or provide negative support.

(Safe) Client receives some positive support (financial/emotional/ material) from extended family or friends.

(Building Capacity) Strong support from extended family or friends.

(Empowered)Has healthy and expanding support network.

Don't Know

Not Applicable

Intimate Relationship(s)(Required)

(In crisis) Abuse is present, or all relations have been severed.

(Vulnerable) Partners do not relate well with one another; potential for abuse or relations being severed.

(Safe) Partners acknowledge and seek to change negative behaviors; are learning to communicate and support.

(Building Capacity) Partners support each other’s efforts.

(Empowered) Relationship is stable and communication is consistently open.

Don't Know

Not Applicable

Parent-child Relations(Required)

(In crisis) There are safety concerns regarding parenting skills; abuse or neglect is present, or all relations have been severed.

(Vulnerable) Parenting skills are minimal; client does not relate well with child(ren); potential for abuse or neglect.

(Safe) Parenting skills are apparent but not adequate; client acknowledges and seeks to change negative behaviors; is learning to communicate and support.

(Building Capacity) Parenting skills are adequate; client supports their child(ren)’s efforts.

(Empowered) Parenting skills are well- developed; parent-child relations are stable and communication is consistently open.

Don't Know

Not Applicable

Education of Client’s Child(ren)(Required)

(In crisis) One or more school-aged children are not enrolled in school.

(Vulnerable) All school-aged children are enrolled in school, but one or more are not attending or only occasionally attending classes OR have unmet educational needs.

(Safe) School-aged children are enrolled in school, but one or more only attend classes most of the time OR are struggling in at least 3, but not all, of their classes.

(Building Capacity) All school-aged children are enrolled in school and attend classes on a regular basis, but one or more are struggling in 1–2 classes.

(Empowered) All school-aged children are enrolled, attend classes on a regular basis, and are performing well in school.

Don't Know

Not Applicable

Childcare(Required)

Crisis: Needs childcare but none is available or accessible (including family members or friends).

Vulnerable: Childcare is unreliable or unaffordable; inadequate supervision is a problem for childcare that is available (including family members or friends).

Safe: Affordable, subsidized but limited (in family members or friends; availability or interest is limited). Building Capacity: Reliable, affordable childcare is available (could be family members or friends); no need for subsidies.

Building Capacity: Reliable, affordable childcare is available (could be family members or friends); no need for subsidies.

Empowered: Able to select quality childcare of choice (could be from among family members or friends).

Don't Know

Not Applicable

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