Full Text
Anoka County FHPAP 11/2011 Anoka County HMIS Self-Sufficiency Matrix Circle one: Initial Interim Exit Client Information First Last Suffix______ Maxis # Instructions: Complete this form for head of household Select only one level in each of the areas below by marking the box next to the appropriate level Assessment 1. Housing □ 1. Homeless or threatened with eviction □ 2. In transitional, temporary or substandard housing; and/or current rent/mortgage payment is unaffordable □ 3. In stable housing that is safe but only marginally adequate □ 4. Household is safe, adequate, subsidized housing □ 5. Household is safe, adequate, unsubsidized housing 2. Employment □ 1. No Job □ 2. Temporary, part-time or seasonal; inadequate pay; no benefits □ 3. Employed full-time; inadequate pay; few or no benefits □ 4. Employed full-time with adequate pay and benefits □ 5. Maintains permanent employment with adequate income and benefits 3. Income □ 1. No Income □ 2. Inadequate income and/or spontaneous or inappropriate spending □ 3. Can meet basic needs with subsidy; appropriate spending □ 4. Can meet basic needs and manage debt without assistance □ 5. Income is sufficient, well managed; has discretionary income and is able to save 4. Food and Nutrition □ 1. No food or means to prepare it. Relies to a significant degree on other sources of free or low-cost □ 2. Household is on food stamps □ 3. Can meet basic food needs but requires occasional assistance □ 4. Can meet basic food needs without assistance □ 5. Can choose to purchase any food household desires 5. Childcare □ 0. N/A □ 1. Needs childcare, but none is available/accessible and/or child is not eligible □ 2. Childcare is unreliable or unaffordable; inadequate supervision is a problem for childcare that is available □ 3. Affordable subsidized childcare is available but limited □ 4. Reliable, affordable childcare is available; no need for subsidies □ 5. Able to select quality childcare of choice 6. Children’s Education □ 0. N/A □ 1. One or more eligible children not enrolled in school □ 2. One or more eligible children enrolled in school but not attending classes □ 3. Enrolled in school, but one or more children only occasionally attending classes □ 4. Enrolled in school and attending classes most of the time □ 5. All eligible children enrolled and attending on a regular basis 7. Adult Education □ 1. Literacy problems and/or no high school diploma/GED are serious barriers to employment □ 2. Enrolled in literacy and/or GED program and/or has sufficient command of English to where language is not a barrier to employment □ 3. Has high school diploma/GED □ 4. Needs additional education/training to improve employment situation and/or to resolve literacy problems to where they are able to function effectively in society □ 5. Has completed education/training needed to become employable. No literacy problems 8. Health Care Coverage □ 1. No medical coverage with immediate need □ 2. No medical coverage and great difficulty accessing medical care when needed. Some household members may be in poor health □ 3. Some members (e.g. children) on □ 4. All members can get medical care when needed but may strain budget □ 5. All members are covered by affordable, adequate health insurance 9. Life Skills □ 1. Unable to meet basic needs such as hygiene, food, activities of daily living □ 2. Can meet a few but not all needs of daily living without assistance □ 3. Can meet most but not all daily living needs without assistance □ 4. Able to meet all basic needs of daily living without assistance □ 5. Able to provide beyond basic needs of daily living for self and family ---PAGE BREAK--- Anoka County FHPAP 11/2011 10. Family/Social Relations □ 1. Lack of necessary support from family or friends; abuse (DV, child) is present or there is child neglect □ 2. 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 □ 3. Some support from family/friends; family members acknowledge and seek to change negative behaviors; are learning to communicate and support □ 4. Strong support from family or friends; household members support each other's efforts □ 5. Has healthy/expanding support network; household is stable and communication is consistently open 11. Transportation/Mobility □ 1. No access to transportation, public or private; may have car that is inoperable □ 2. Transportation is available but unreliable, unpredictable, unaffordable; may have car but no insurance, license, etc. □ 3. Transportation is available and reliable but limited and/or inconvenient; drivers are licensed and minimally insured □ 4. Transportation is generally accessible to meet basic travel needs □ 5. Transportation is readily available and affordable; car is adequately insured 12. Legal □ 1. Current outstanding tickets or warrants □ 2. Current charges/trial pending; noncompliance with probation/parole □ 3. Fully compliant with probation/parole terms □ 4. Has successfully completed probation/parole within past 12 months; no new charges filed □ 5. No felony criminal history and/or no active criminal justice involvement in more than 12 months 13. Did the household leave any of these places? Place 3 months before program entry 3-6 months ago Place 3 months before program entry 3-6 months ago Adoptive home □ Yes □ Yes Mental Health Treatment Facility or Hospital □ Yes □ Yes County jail or work house □ Yes □ Yes Combined MI/CD treatment facility □ Yes □ Yes Drug or Alcohol Treatment Facility □ Yes □ Yes Foster Home □ Yes □ Yes Group Home □ Yes □ Yes Half-way House □ Yes □ Yes Juvenile Detention Center □ Yes □ Yes Orphanage □ Yes □ Yes Residence for People with Physical Disabilities □ Yes □ Yes State or Federal Prison □ Yes □ Yes 14. Has the client ever been a domestic violence victim/survivor? If yes, when did the most recent episode occur? Adult/Unaccompanied Youth Household Member Name Yes No Prefer not to answer Within the past 3 months 3-6 months ago 6-12 months ago More than 1 year ago Prefer not to answer 1. 2. 15. Has the client ever served on active duty in the United States Armed Forces (U.S. Military Veteran Status)? (Adults 18+ only) Adult Household Member Name Yes No Prefer not to answer 1. 2. 3.