WAG 02-03-02: Manual Forms

In all local offices except those equipped with the Family Assessment in VCM, the Family Assessment must be completed through the use of manual forms.

The Family Assessment may be completed through the use of:

  • separate forms which cover specific areas of the assessment, or
  • one form completed in a free-style manner.

The Family Assessment forms (Form 4001 series) are a tool to guide the conversation. Each form contains questions that serve as a guide. Follow the questions as outlined on each of the assessment forms, or restructure or rephrase the questions to fit your interview style and to elicit the information you need. When using the questions as outlined, it may be necessary to ask each one. Ask only the questions that are relevant.

Following is a brief summary of each form used in the Family Assessment Process that covers a specific area of the assessment:

  • Background (Form 4001)

    Information gathered through the use of Form 4001 identifies specific areas of concern. This part of the assessment is extremely important. Use your interviewing skills to elicit information from the client and to determine if more discussion on a specific topic (e.g., family health, substance abuse) is needed. When an area of concern is identified, gather more information to fully evaluate the issue.

    This part of the assessment must be completed for each person being assessed.

  • Employment (Form 4001A)

    Use Form 4001A to help determine suitable employment options. This area gathers information to determine a person's employment interests, current and past work history, and barriers to employment. 

  • Individual and Family Health (Form 4001B)

    Use Form 4001B to identify general health issues. Potential referrals may include, but are not limited to:

  • substance abuse;
  • family planning; and
  • prenatal care.
  • Treatment (Form 4001C)

    Use Form 4001C to help determine whether to make a referral for: 

  • substance abuse,
  • domestic violence, and/or
  • mental health.
  • Treatment Indicators Checklist (Form 4001D)

    Use Form 4001D as a guide to determine if a referral is needed for substance abuse, domestic violence, or mental health. Form 4001D contains a list of observable behaviors and signs that may indicate that a referral for domestic violence, mental health, and/or substance abuse may be needed. 

  • Elderly (Form 4001E)

    Use Form 4001E to gather information about specific needs or problems an elderly person faces. Complete it for any applicant age 60 or over. Potential referrals may be made for, but are not limited to:

    • community services,
    • home services, and
    • elder abuse.
  • Infant, Child, and Teen Health (Form 4001F)

    Use Form 4001F to identify specific health issues for children and teens. Potential referrals may include, but are not limited to:

    • children's health (e.g., school attendance, overall health, early intervention, and mental health); and
    • child care.
  • Education and Training (Form 4001G)

    Use Form 4001G to gather information about the client's educational history and potential education and training goals. Referrals may be made to enroll the client in education or training programs which may fit their plans. 

Family Assessment - Free Style (Form 4001H) allows you to choose to complete the assessment without using the specific Family Assessment forms outlined above. If the assessment is completed in a free-style manner, all assessment areas must still be covered. The free-style write-up must include the same degree of information that would be gathered if the detailed questions were asked.

If a person says they only want rehabilitation services or they have a disability which keeps them from working, complete the Checklist for Referral to Vocational Rehabilitation (Form 4020A) and refer them for rehabilitative services.