FY12 Exhibit K Assessment Tool.doc

Date of Referral

State of New Mexico Human Services Department New Mexico Works Assessment Form

DEMOGRAPHIC INFORMATION

1. Client Name:

(Last)

(First)

(MI)

2. Client Address: ______________

3. Client Telephone Number:

4. Social Security #: _______ - _____ - _________

5. ____ Marital Status:

1. Divorced

3. Married, but Separated

5. Widowed

2. Married, Living w/ Spouse

4. Single, Never Married

6. Other ________________

6. Date of Birth: ____ / ____ / ____ mm dd yy

7. ____ Gender

1. Male 2. Female

8. ____ Ethnicity –Hispanic or Latino

1. No 2.

9. ____ Race:

1. American Indian/Alaskan Native

4. Native Hawaiian or other Pacific Islander

2. Asian

5. White

3. Black or African American

6. Other, specify _____________________

Sources of Stress “What brings you here today?”

Please list the reasons that bring the client here today. This may include certain problems, issues, significant losses or changes that are causing stress in their life.

10A.

10B.

10C.

10D.

Adult Strength Scale Please have the client complete the following Adult Strength Scale. In the event the client is not able to fill the scale out individually, please read each statement to the client and circle their response.

It may be helpful to substitute a scale of “1 to 5” when reading the questions to the client, 1 being never and 5 being all the time.

11. _____ The Adult Strength Scale was

1. Completed by the client

2. Read to the client

Adult strength scale Please read the following questions and circle the answer that most closely describes your situation.

Never Just a Not Pretty Very N/A

Little Sure Much Much

(1) (2)

(3) (4) (5) (0)

Home

12. My family is a source of support

Never Just a little Not Sure Pretty Much Very Much N/A for me

13. I get along with my partner/

Never Just a little Not Sure Pretty Much Very Much N/A significant other

14. I am physically healthy

Just a little Not Sure Pretty Much Very Much N/A

15. I am a good parent

Not Sure Pretty Much Very Much N/A Work/School/Training

16. I get to my activity on time

Never Just a little Not Sure Pretty Much Very Much N/A

17. I get along with my co-workers/

Never Just a little Not Sure Pretty Much Very Much N/A classmates

18. I am respected by my supervisor(s)/ Never Just a little Not Sure Pretty Much Very Much N/A teacher(s)

19. I enjoy working

Not Sure Pretty Much Very Much N/A

20. I have work/training goals

Never Just a little

21. I am a hard worker

Not Sure Pretty Much Very Much N/A

22. I balance home and work/school

Never Just a little Not Sure Pretty Much Very Much N/A

23. I can pay attention to what I’m doing Never Just a little Not Sure Pretty Much Very Much N/A Emotional

24. I cope well when things are bad

Never Just a little

25. I am satisfied with life

Not Sure Pretty Much Very Much N/A

26. I accept responsibility for my mistakes Never Just a little

27. I think before I act

28. I have good self-esteem

Not Sure Pretty Much Very Much N/A Social

29. I make and keep friends

30. I stand up for myself

31. I get along with others

Not Sure Pretty Much Very Much N/A

32. My community is a source of support Never Just a little Not Sure Pretty Much Very Much N/A for me

33. I attend church or another organization Never Just a little Not Sure Pretty Much Very Much N/A Problems That You Are Struggling With Please read each choice to the client and check (() all that apply

34. ( ) Difficulty meeting your family’s basic needs (such as food, clothing, housing)

52. ( ) Death of a loved one

35. ( ) Childcare

53. ( ) Major losses/difficult changes

36. ( ) Transportation

54. ( ) Sleeping problems

37. ( ) Child behavioral problem

55. ( ) Eating problems

38. ( ) Child health problem

56. ( ) Depression

39. ( ) Stress

57. ( ) Anxiety or panic attacks

40. ( ) Unemployed

58. ( ) Nerve problems

41. ( ) Physical health

59. ( ) Sexual Abuse - Adult/Child

42. ( ) Job/school problem

60. ( ) Suicidal, or thoughts of hurting yourself

43. ( ) Low self - esteem

61. ( ) Suicidal actions

44. ( ) Anger/temper problems

62. ( ) Thoughts of hurting someone else

45. ( ) Communication/language problems

63. ( ) Rape survival

46. ( ) Marital/relationship problems

64. ( ) Violence in family-actual or threatened

47. ( ) Legal problems

65. ( ) Alcohol

48. ( ) Probation

66. ( ) Drugs

49. ( ) Compulsive gambling

67. ( ) Other______________________

50. ( ) Learning problem/disability

51. ( ) Racism

Additional Space (interviewer comments if needed): __________________________________________________________________________________________

School/Work History Please ask the client the following questions and indicate their response in the space provided.

68. ____ Did you have any problems learning in elementary, middle school or junior high school?

1. No

2. Yes

69. ____ What is the highest grade you completed? (circle the number of the highest grade completed)

70. ____ Did you have one of the following?

1. Certificate

2. Diploma

3. GED

4. N/A – did not graduate from high school

71. ____ Were you in a special education or “resource” class at any point in school?

72. ____ Are you currently a student?

If No, go to question 74. If Yes, answer question 73.

73. ____ In what kind of education/training are you currently enrolled?

1. High school

3. Job training (specify) _________________________

2. GED/ABE classes

4. Other (specify) ______________________________

74. ____ Have you ever been employed?

If No, go to question 77. If Yes, answer question 75 and 76.

75. ____ How many months have you worked during the past 12 months?

76. ____ Do you have a job right now?

1. No

2. Yes

Health Please ask the client the following questions and indicate their response in the space provided.

77. ____ Do you currently have any diagnosed physical/emotional/medical conditions?

1. No

2. Yes

If No, go to question 79. If Yes, answer question 78.

78. If Yes, what conditions? (check all that apply)

___ 1. Asthma

___ 7. Mental health problems _______________

___ 2. Diabetes/sugar

___ 8. Pregnancy

___ 3. Epilepsy/seizure disorder

___ 9. Vision impairment

___ 4. Head injury or other neurological disorder ___ 10. High blood pressure

___ 5. Hearing loss

___ 11. Other (specify) ______________________

___ 6. Disability _____________________

79. ____ Have you ever been treated for emotional or nerve problems?

Current medication you regularly take - please include prescription, over the counter, and any herbal remedies (if none, write “None”)

Name of Medication

HISTORY OF COUNSELING

Please indicate the client’s response in the space provided.

Previous or Current Counseling (if none, write “None”) Therapist or Agency

From/to

Focus of Counseling

What was helpful and/or not helpful about your previous/current counseling experience? __________________________________________________________________________________________

Drugs and Alcohol Please circle the client’s response to the following questions.

80. How often do you have a drink of alcohol?

Never (1) Monthly or less (2) 2-4 times/mo. (3) 2-3 times/wk. (4) 4 or more times/wk. (5)

81. How often do you use drugs?

Never (1) Monthly or less (2) 2-4 times/mo. (3) 2-3 times/wk. (4) 4 or more times/wk. (5)

82. How often during the past year have you found that you drank or used drugs more than you intended to?

Less than monthly (2)

Monthly (3) Weekly (4) Daily or almost daily (5)

83. How often during the last year have you failed to do what was normally expected from you because of drinking or using drugs?

Monthly (3) Weekly (4) Daily or almost daily (5)

84. How often during the last year have you been unable to remember what happened the night before because you had been drinking or using drugs?

Monthly (3) Weekly (4) Daily or almost daily (5)

Family Information Please ask the client the following questions and indicate their response in the space provided.

85. Please list the people that you currently live with

86. ____ How old were you when your first child was born? (Enter age in years).

87. ____ Are all your children currently living with you?

If no, please give names and ages __________________________________________________________________________________________

88. ____ Are any of your children having problems such as behavior problems, problems in school, bedwetting, medical problems, etc?

If yes, which child(ren) and describe the problem(s)

89. ____ Has CYFD (Children Youth & Family Department) ever been involved with your child(ren)?

If yes, why

90. ____ Have you ever been hit, slapped, kicked, punched or abused in any other way by a friend or loved one?

1. None disclosed at this time

91. ____ Have you ever experienced emotional abuse (name calling, someone telling you that you are no good, stupid, etc.) by a friend or loved one?

1. None disclosed at this time

If yes to questions 90 OR 91, answer question 92. Otherwise, skip to question 93.

92. ____ How long ago did the most recent event happen?

1. Within last six months

2. Six months to 1 year

3. Over a year

Current Functioning

93. Please read the following statement to the client and circle their response. “Please think about how you are coping with your current situation. On a scale of 0 to 10, 10 being the best and 0 the worst, what number best describes how you are coping now.”

0--------1--------2--------3--------4--------5--------6--------7--------8--------9--------10 Goals in Counseling Check here if not applicable _____

Goals are very important in counseling. They provide a focus and direction to services. Please ask the client the goal(s) that they hope to address and achieve in counseling. Please be as specific as possible.

94A.

94B.

94C.

94D.

***************************End of Assessment with Client*********************************

Counselor Impressions Based on your interview, please indicate whether or not you believe there are barriers to achieving self-sufficiency in the following areas for this client at this time.

95. ____ Education background

96. ____ Possible learning disabilities

97. ____ Work history

1. No

98. ____ Family/parenting needs

99. ____ Relationships

100. ____ Child behavioral problems

101. ____ Family violence

102. ____ Inadequate basic needs

103. ____ Family environment and upbringing

104. ____ Physical health of participant

105. ____ Physical health of children/family members

106. ____ Alcohol/drug abuse

107. ____ Mental health issues

108. ____ Legal issues

Outcome Category

109. ____ What is the client's designated "outcome category"? (circle one category)

A No barriers found. This client will not receive New Mexico Works Counseling Services.

B Slight barriers found. Counselor will provide a few services but client will still have a traditional work plan.

C Major barriers present that allow for modifications to the total hours on the IRP, modified sanction procedures and/or modified activities.

D Severe barriers present, pursue exemption; continuation with New Mexico Works Counseling Services is voluntary; no work or work-related activities are included on the IRP.

110. NM Works Case Manager Supervisor

Case Manager Supervisor’s signature:

111. County:

112. Date Completed: _____ / _____ / ____ mm dd yy

Exhibit K - FY12 NMW SOW