4People.org Self Sufficiency Form

Instructions: Rate yourself and your family. All people need help at some time in their lives, and some of these situations can easily be corrected with a little help from friends. Should you fall below 3 in a category, you might want to seek help from the community there is HELP and HOPE for the future, see 4People.org. Please see printed version

1. Income

No Income
Inadequate income and/or spontaneous or inappropriate spending
Can meet basic needs with subsidy; appropriate spending
Can meet basic needs and manage debt without assistance
Income is sufficient, well managed; has discretionary income and is able to save

2. Employment

No Job
Temporary, part-time or seasonal; inadequate pay; no benefits
Employed full-time; inadequate pay; few or no benefits
Employed full-time with adequate pay and benefits
Maintains permanent employment with adequate income and benefits

3. Shelter

Homeless or threatened with eviction
In transitional, temporary or substandard housing; and/or current rent/mortgage payment is unaffordable
In stable housing that is safe but only marginally adequate
Household is safe, adequate, subsidized housing
Household is safe, adequate, unsubsidized housing

4. Food

No food or means to prepare it. Relies to a significant degree on other sources of free or low-cost +
Household is on food stamps
Can meet basic food needs but requires occasional assistance
Can meet basic food needs without assistance
Can choose to purchase any food household desires

5. Adult Education

Literacy problems and/or no high school diploma/GED are serious barriers to employment
Enrolled in literacy and/or GED program and/or has sufficient command of English to where language is not a barrier to employment
Has high school diploma/GED
Needs additional education/training to improve employment situation and/or to resolve literacy problems to where they are able to function effectively in society
Has completed education/training needed to become employable. No literacy problems

6. Legal

Current outstanding tickets or warrants
Current charges/trial pending; noncompliance with probation/parole
Fully compliant with probation/parole terms
Has successfully completed probation/parole within past 12 months; no new charges filed
No felony criminal history and/or no active criminal justice involvement in more than 12 months

7. Health Care

No medical coverage with immediate need
No medical coverage and great difficulty accessing medical care when needed. Some household members may be in poor health
Some members (e.g. children) on other programs. ?
All members can get medical care when needed but may strain budget
All members are covered by affordable, adequate health insurance

8. Life Skills

Unable to meet basic needs such as hygiene, food, activities of daily living
Can meet a few but not all needs of daily living without assistance
Can meet most but not all daily living needs without assistance
Able to meet all basic needs of daily living without assistance
Able to provide beyond basic needs of daily living for self and family

9. Mental Health

Danger to self or others; recurring suicidal ideation; experiencing severe difficulty in day-to-day life due to psychological problems
Recurrent mental health symptoms that may affect behavior but not a danger to self/others; persistent problems with functioning due to mental health symptoms
Mild symptoms may be present but are transient; only moderate difficulty in functioning due to mental health problems
Minimal symptoms that are expectable responses to life stressors; only slight impairment in functioning
Symptoms are absent or rare; good or superior functioning in wide range of activities; no more than every day problems or concerns

10. Substance Abuse

Meets criteria for severe abuse/dependence; resulting problems so severe that institutional living or hospitalization may be necessary
Meets criteria for dependence; preoccupation with use and/or obtaining drugs/alcohol; withdrawal or withdrawal avoidance behaviors evident; use results in avoidance or neglect of essential life activities
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 that have persisted for at least one month
Use during 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
No drug use/alcohol abuse in last 6 months

11. Family Relations

Lack of necessary support from family or friends; abuse (DV, child) is present or there is child neglect
Family/friends may be supportive but lack ability or resources to help; family members do not relate well with one another; potential for abuse or neglect
Some support from family/friends; family members acknowledge and seek to change negative behaviors; are learning to communicate and support
Strong support from family or friends; household members support each other's efforts
Has healthy/expanding support network; household is stable and communication is consistently open

12. Transportation/Mobility

No access to transportation, public or private; may have car that is inoperable
Transportation is available but unreliable, unpredictable, unaffordable; may have car but no insurance, license, etc.
Transportation is available and reliable but limited and/or inconvenient; drivers are licensed and minimally insured
Transportation is generally accessible to meet basic travel needs
Transportation is readily available and affordable; car is adequately insured

13. Community Involvement

No community involvement; in "survival" mode
Socially isolated and/or no social skills and/or lacks motivation to become involved
Lacks knowledge of ways to become involved
Some community involvement (advisory group, support group) but has barriers such as transportation, childcare issues
Actively involved in community

14. Safety

Home or residence is not safe; immediate level of lethality is extremely high; possible CPS involvement
Safety is threatened/temporary protection is available; level of lethality is high
Current level of safety is minimally adequate; ongoing safety planning is essential
Environment is safe, yet future of such is uncertain; safety planning is important
Environment is apparently safe and stable

15. Childcare

N/A
Needs childcare, but none is available/accessible and/or child is not eligible
Childcare is unreliable or unaffordable; inadequate supervision is a problem for childcare that is available
Affordable subsidized childcare is available but limited
Reliable, affordable childcare is available; no need for subsidies
Able to select quality childcare of choice

16. Children ’s Education

N/A
One or more eligible children not enrolled in school
One or more eligible children enrolled in school but not attending classes
Enrolled in school, but one or more children only occasionally attending classes
Enrolled in school and attending classes most of the time
All eligible children enrolled and attending on a regular basis

17. Parenting Skills

N/A
There are safety concerns regarding parenting skills
Parenting skills are minimal
Parenting skills are apparent but not adequate
Parenting skills are adequate
Parenting skills are well developed

If you wish to have a case manager contact you to help you find services, please fill in the following information:

Name (First and Last)
Address line 1
Address line 2
City
State
Zip
County (required) To determine if services are in your area.
Telephone Number
E-mail

Once you submit this form a preview screen will come up. If all of the information is correct, you may print a copy of this form for your records before pressing the SUBMIT button

4People Self Sufficiency On Line Form