| Education |
| What level of education have you completed or are you currently enrolled in? (Please specifiy grade level completed, or note GED, High School Diploma, College Degree, or any college credit obtained.) |
1
1.5
|
1
1.5
|
- Post-secondary education or training
- Positive attitude toward learning
- Sets and pursues long-range career & educational goals
- Can pursue educational or personal development goals without additional resources or support
|
|
Do you have plans to pursue any educational or career related goals?
YES or NO
If yes, what do you have planned & when?
|
2
2.5
|
2
2.5
|
- High school or equivalent eudcation or enrolled for same
- Enrolled in adult education or vocational education
- Has solid plans to pursue educational training of some sort
- Capable of pursuing education or personal development goals with little assistance
|
|
Is there anything we can do to help you reach your educational goal? YES or NO
If yes, what?
|
3
3.5
|
3
3.5
|
- Considering personal education needs and optoins
- Less than 9th grade education
- Can set and pursue education goals with assistance
- Has knowledge of and access to resources to enhance personal development or education
|
| If you had to tell your child(ren) one thing about learning, what would you say? |
4
4.5
|
4
4.5
|
- Less than 6th grade education
- Does not consider learning a priority
- Doesnot or cannot set or pursue systemic career and personal education goals
- Very limited ability to participate in educational or personal development goals
|
| Notes/Comments: |
5
5.5
|
5
5.5
|
- Little to no formal education
- No interest in or access to remedial education
- Unable to pariticpate in educational activities
- Pursuing educational or personal development goals is not feasible
|
| Employment |
| What type of skills, interests, or talents do you have? |
1
1.5
|
1
1.5
|
- Currently employed in a stable job
- Current job has a benefit package
- Solid skills and confidence in skills
- Currently not interested in employment by choice (job not needed or not feasible)
|
|
Are you currently employed? YES or NO
If yes, where?
How long?
|
2
2.5
|
2
2.5
|
- Has marketable skills
- Has some benefits
- Employment potential for advancement
- Currently or recently employed or unemployed by choice (not needed or feasible)
|
|
If not employed, do you wish to obtain employment? YES or NO
Do you need assistance with job skills?
YES or NO
|
3
3.5
|
3
3.5
|
- Learning or willing to learn more marketable skills as needed
- History of seasonable or temporary employment
- Inadequate hours, benefits, stability, limited advancement potential
- Actively seeking employment
|
|
Are other members of the household employed? YES or NO
If yes, who?
Where is he/she employed?
What other types of work have you done in the past and what have you liked/disliked about the work?
|
4
4.5
|
4
4.5
|
- Minimum job skills
- No benefits, not sure where to find next job
- History of performance problems at work
- No career plans, employment needed
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- Unemployed, no leads for a job
- No positive work history
- No interest in employment or unable to work due to emotional/physical status
- Employment greatly needed
|
| Housing/Community |
|
Do you rent, own, lease, or have other living arrangements?
How many people live in your household?
|
1
1.5
|
1
1.5
|
- Lives in housing of choice, or is satisifed with housing/community situation
- Rent or payment options seem feasible and can be made without major concerns
- Owns or has long-term occupancy
- Housing is safe and meets family's needs
|
|
Are payments for housing affordable for you? YES or NO
Do you have concerns about your current housing situation? YES or NO
What are your concerns (check for safety and healthy living conditions)?
|
2
2.5
|
2
2.5
|
- Lives in or has access to adequate housing
- Rent or payment options can be met but are sometimes a concern
- Safe home or neighborhood or perceived as such by family
- Tenancy is secure (or has been secure) for more than one year
|
|
Do you feel that your community or neighborhood is a safe place to live?
Please explain:
|
3
3.5
|
3
3.5
|
- Payments for housing are difficult to make wihtout assistance
- Tenancy is secure for at least 6 months
- Housing is not hazardous or unhealthy
- Family feels neighborhood is relatively safe
|
| What do you think would make your community a better place to live? |
4
4.5
|
4
4.5
|
- Lives in temporary or transitional housing
- Uncertain of where family will live a month from now
- Lives in unsafe, deteriorating, or overcrowded housing
- Finances for stable housing are not routinely available
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- Lives in dangerous conditions
- Homeless or on the verge of homelessness
- Has history of consistent homelessness
- Unable to secure housing without extensive resources or help
|
| Transportation |
|
Do you have access to safe transportation? YES or NO
What is your main source of transportation?
- Own Vehicle
- Friend's/Family Member's Vehicle
- Bus or Other Public Transportation
|
1
1.5
|
1
1.5
|
- Has current driver's license
- Auto is fully insured with comprehensive or adequate coverage
- Has choice of transportation and/or access to transportation virtually all the time
- Able to repair (or obtain repairs for) vehicle when needed; vehicle is safe
|
|
Do you have a valid driver's license?
YES or NO
If no, have there been porblems with obtaining or keeping a license? Explain:
|
2
2.5
|
2
2.5
|
- Has license
- Has basic insurance coverage
- Has adequate driving record
- Has and maintains own vehicle or other means of transportation
|
|
In the State of Illinois, it is the law that all children under 40 lbs. be in a child safety seat while traveling. Do you need information about obtaining or correctly using a car seat for your child? YES or NO
It is also the law in Illinois that all passengers wear seat belts while traveling. Do you need information about obtaining or using seatbelts in your main transportation source? YES or NO
|
3
3.5
|
3
3.5
|
- Generally has access to some form of safe transportation as needed
- Has driver's license but history of driving or license problems
- Driving not a major concern or need
- Minimal or lack of insurance
|
|
Do you have auto insurance? YES or NO
Do you need information on possible resources regarding safe driving practices or about insurance for your car? YES or NO
|
4
4.5
|
4
4.5
|
- Does not have a license
- Is driving without a license or without insurance or both
- Has upaid parking tickets or has other legal issues related to driving
- Does not have safe or reliable transportation ormeans to obtain it
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- Has revoked or suspended license, not insurable
- No access to transportation for basic needs
- No money to obtain insurance
- Previously incarcerated for traffic violations
|
| Services & Resources |
| If you found yourself in need of service or information about a service, what might you do? (This is an excellent opportunity for you to explain Advocacy Services and the Community Resource Guide.) |
1
1.5
|
1
1.5
|
- Has knowledge of available services
- Is able to access needed services when necessary
- Knows where to find help if needed
- Requires few (or no) formal resources
|
| Do you feel you have knowledge of the services that are available for a person in your community? YES or NO |
2
2.5
|
2
2.5
|
- Has basic knowledge of existing services
- Can access services independently
- Lives in community where resources are adequate
- Can access services with help
|
| Do you or have you used agency/program services? YES or NO |
3
3.5
|
3
3.5
|
- Has some knowledge of available services
- Only accesses needed services/resources in an emergency
- Lives in a community where resources are adequate
- Can access services with help
|
| If you have used agency/program services, what services were they and when did you use them? |
4
4.5
|
4
4.5
|
- Has minimal knowledge of available services
- Does not utilize resources appropriately
- Lives in a community where resources are limited
- Needed services typically initiated by an outside source
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- Has no knowledge of what services are available or how to find out what services are available
- Services or resources are utilized only when initialized by an outside source
- Lives in a community where resources are extremely limited
- Services and resources are sometimes misused
|
| Special Needs/Familiy Support |
|
Do you have a child or family member with a disability or special need? YES or NO
How would you describe the need?
Is there something we could do to meet that need?
|
1
1.5
|
1
1.5
|
- Special needs family member cares for self as appropriate or family meets needswith little or no outside assistance
- Family notese at least 4 sources of support and accesses support as needed
- Recognizes strengths and needs of family and works to build on strengths
- Emotional needs are few and are recognized as well as being met appropriately
|
|
Do you have people you can turn to when you need help, advice, or just someone to listen? YES or NO
What are some of your family's strengths?
|
2
2.5
|
2
2.5
|
- Special needs family member has areas of minor dependence that are necessary
- Family notes at least 2 sources of support and accesses support as needed
- Recognizes strengths of family
- Emotional needs are recognized and met appropritely
|
Who has been helpful to you in raising your child(ren) and/or coping with daily situations? (circle all that apply)
- Parents
- Friends
- Neighbors
- Other Family Members
- Spouse/Partner
- Other Agencies
- Church
- Counselor
- Head Start
- Day Care
- Others
- No One Noted
|
3
3.5
|
3
3.5
|
- Special needs family member relies on others for routine help; some emotional dependence
- Family notes at least 1 souce of support
- Has difficult recognizing strengths of family
- Family has 3 or more emotional needs not beingmet at the present time
|
|
Are there specific emotional health needs that we might be able to help you with?
YES or NO
If yes, please specify:
|
4
4.5
|
4
4.5
|
- Special needs family member has minimal independence functioning; cannot live alone
- Family does not access support from others
- Does not recognize family strengths
- Emotional needs of family are numerious and are not being addressed
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- Special needs family member unable to function independently; cannot survive without outside help
- No sources of support are noted or recognized
- Family does not recognize family strengths
- Emotional needs of family are numerous and are not being addressed
|
| Family Wellness |
| Do you have access to total care for adult members of your family? (vision, dental, medical, mental health services, etc.) YES or NO |
1
1.5
|
1
1.5
|
- Very attentive to health care issues
- Report quality and accessible medical care
- Wellness needs are being met and there seems to be preventative care
- No history of alcohol/drug abuse
|
| If yes, how are these needs met? |
2
2.5
|
2
2.5
|
- Adequate medical and physical care provided
- Wellness needs are being met as they occur
- Several medical problems noted and are being addressed
- No history of alcohol/drug abuse
|
|
Does your child(ren) have a doctor/medical care available when he/she is ill?
YES or NO
If yes, please specify what type of coverage:
(If eligible, but not currently covered, ensure that the family receives, completes, and returns a KCHIP application.)
|
3
3.5
|
3
3.5
|
- Family reports inadequate or inaccessible health care
- Wellness needs not met in a timely manner
- Numerous medical problems noted some of which are not being addressed
- Suspected or reported drug/alcohol abuse in the past
|
|
Are there current concerns about alcohol/drug use for you or anyone in your household? YES or NO
Have you or other persons in your household participated in treatment for drugs and/or alcohol in the past year? YES or NO
|
4
4.5
|
4
4.5
|
- Minimal attention to medical/physical care
- General inadequate care, or requires extensive care
- Medical problems noted are severe, potentially harmful
- Suspected or reported history of alcohol/drug abuse, and possible current use
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- Child(ren)'s health is endangered
- Medical problems are not being addressed; no care is being received
- Home environment does not promote healthy living
- Suspected or reported history of alcohol/drug abuse in the past and possible current use
|
| Family Finances |
Sometimes families have a hard time getting by on the money available. Please answer "YES" or "NO" to the following:
- I am able to pay bills on time
- I know how to budget my money
- It's difficult to meet basic needs (food, clothing, etc.)
- I have a lot of debt
- I have good credit
- I am not able to get credit
- I have no credit
- I am able to save some money
- I have a checking account
- I have a savings account
- There is extra money for "wants" (aside from basics)
- I think my income will increase in the next year
- I have a reliable source of income
- I have to rely on others for financial assistance
|
1
1.5
|
1
1.5
|
- Sufficient income to meet and allow for "extras" and/or can save money
- Keeps track of expenditures or has a budget
- Stable, steady income
- Consistently pays bills on time
|
|
Do you or your family have other financial needs at this time? YES or NO
If yes, please specifiy:
|
2
2.5
|
2
2.5
|
- Sufficient income to meet basic needs
- Attempts to budget money
- Typically pays bills on time
- Is able to save money
|
| Would you like information about reducing debt? YES or NO |
3
3.5
|
3
3.5
|
- Minimally adequate income
- Is not able to save money
- Not able to make timely payments on a routine basis
- No budget or financial plan in place
|
| Would you like information about credit counseling? YES or NO |
4
4.5
|
4
4.5
|
- Occasionally able to meet basic needs
- No credit
- Overwhelming debt load
- Relies on others for financial assistance
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- Little or no money
- Cannot meet basic needs
- Is not ableto pay bills
- Has had legal problems due to finances
|
Child Care: How are children being cared for? (If using a combination, circle all that apply.)
- Head Start
- School
- Home
- Daycare
- Family/Relative Home
- Other:
|
1
1.5
|
1
1.5
|
- High quality, affordable child care is being used, or is not needed
- Has a consistent, reliable resource for child care with back up available
- Minimal concerns about child care; is able to address concerns appropriately
- Knows what to look for to find quality child care
|
|
Do you feel your child has quality, affordable child care? YES or NO
If no, what are your concerns?
What would make child care easier for your family?
|
2
2.5
|
2
2.5
|
- Child care is hard to find and afford, but family is able to provide care or it is not needed
- Generally satisfied with chidl care status and alternatives
- Reliable source of child care, but limited back up resources
- Knows what to look for to find quality child care
|
| Do you have friend/family members who can "pitch in" if you need last minute child care? YES or NO |
3
3.5
|
3
3.5
|
- Caregiver not always available or affordable, but is needed
- Has minor concerns about chidl care status, but is working toward a resolution
- Unsure of what to look for to find high quality child care
- Lack of child care is detrimental to family
|
Families sometimes have a difficult time finding child care. Which of the following statements do you think are true? (circle all that apply)
- I know what to look for in a good child care provdier
- I have several child care choices available
- I do not need to use additional child care
- I am not able to afford child care
- Finding quality child care is difficult
- I need full day child care
- I need second or third-shift day care
|
4
4.5
|
4
4.5
|
- Rarely able to find or afford quality child care
- Limited resources or backup for child care
- Has several concerns about child care
- Uses inappropriate child care
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- No resources for child care
- Does not know what to look for to find quality child care
- Lack of child care is preventing parental growth/progress
- Uses inappropriate child care
|
| Parenting |
Which statements do you agree with regarding parenting? (circle all that apply):
- I feel I am a good parent
- I know and understand my child's needs
- I have a consistent method of discipline
- We have daily routines in our home
- I enjoy being a parent
- We have family rules
- My child has other adult roles models in his/her life
- My child enjoys being at home
- I feel comfortable showing affection to my child
- My child knows he/she is loved
|
1
1.5
|
1
1.5
|
- Consistent, observable, age-appropriate parenting practices
- Enjoys being a parent and seems confident in skills
- Understands child's needs and provides accordingly
- Children know they are loved, and are show affection
|
|
Do you have concerns about your child's behavior? YES or NO
If yes, please explain:
|
2
2.5
|
2
2.5
|
- Reasonably consistent and appropriate parenting practices
- Has an understanding of child's needs and attempts to meet them
- Children know they are loved
- Appears to have an effective method of discipline
|
|
How are children disciplined at home?
What is the most difficult part of parenting for you?
|
3
3.5
|
3
3.5
|
- Some daily routines
- Inconsistent or ineffective discipline methods
- Unsure of parental role
- Some understand of child's needs or development
|
|
Do you have parenting concerns?
YES or NO
If yes, what are they?
|
4
4.5
|
4
4.5
|
- Minimal routines in the home
- Discipline methods seems to be inappropriate
- History of parental problems
- Little understanding of child development or needs
|
| Comments/Notes: |
5
5.5
|
5
5.5
|
- No routine or consistency
- History of serious parental problems
- Discipline is rigid, harsh, or extremely permissive
- No understanding of child development or needs
|
