Self Sufficiency Matrix Name First Middle Last Email* Housing 1. Homeless or threatened with eviction 2. In transitional, temporary or substandard housing; and/or current rent/mortgage payment is unaffordable (over 30% of income) 3. In stable housing that is safe but only marginally adequate 4. Household is in safe, adequate subsidized housing 5. Household is safe, adequate, unsubsidized housing 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 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 Food 1. No food or means to prepare it. Relies to a significant degree on other sources of free or low-cost food 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 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 Children’s Education (0=n/a) 1. One or more eligible children not enrolled in school 2. All eligible children enrolled in school, but one or more children 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 and making progress 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 Legal 1. Current outstanding tickets or warrants or other serious unresolved legal issues 2.Current charges/trial pending; noncompliance with probation/parole; legal issues impacting housing qualifications 3. Fully compliant with probation/parole terms; past non-violent felony convictions; working on plan to resolve other legal issues 4. Has successfully completed probation/parole within past 12 months, no new charges filed; recently resolved other legal issues 5. No active legal issues in more than 12 months and/or no felony/significant legal/criminal history Health Care 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 Medi-Cal, but adults lack coverage 4. All members can get medical care when needed, but may strain budget 5. All members are covered by affordable, adequate health insurance 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 Mental Health 1. Danger to self or others; recurring suicidal ideation; experiencing severe difficulty in day-to-day life due to psychological problems 2. Recurrent mental health symptoms that may affect behavior, but not a danger to self/others; persistent problems with functioning due to mental health symptoms 3. Mild symptoms may be present but are transient; only moderate difficulty in functioning due to mental health problems 4. Minimal symptoms that are expectable responses to life stressors; only slight impairment in functioning 5. Symptoms are absent or rare; good or superior functioning in wide range of activities; no more than every day problems or concerns Substance Abuse 1. Meets criteria for severe abuse/dependence; resulting problems so severe that institutional living or hospitalization may be necessary 2. 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 3. 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 have persisted for at least one month 4. Client has used 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 5. No drug use/alcohol abuse in last 6 months Family Relations 1. Lack of necessary support form 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 Mobility 1. No access to transportation, public or private; may have car that is inoperable 2. Transportation is available (including bus), but unreliable, unpredictable, unaffordable; may have care but no insurance, license, etc 3. Transportation is available (including bus) and reliable, but limited and/or inconvenient; drivers are licensed and minimally insured 4. Transportation (including bus) is generally accessible to meet basic travel needs 5. Transportation is readily available and affordable; car is adequately insured Community Involvement 1. Not applicable due to crisis situation; in “survival” mode 2. Socially isolated and/or no social skills and/or lacks motivation to become involved 3. Lacks knowledge of ways to become involved or new to community 4. Some community involvement (church, advisory group, support group), but has barriers such as transportation, childcare issues 5. Actively involved in community (church, etc.) Safety 1. Home or residence is not safe, lethality is high 2. Safety is threatened, temporary protection is available, lethality is high 3. Safety is minimally adequate, safety planning is essential 4. Home is safe, however, future is uncertain, safety planning is important 5. Home is apparently safe and stable Parenting Skills (0=n/a) 1. Parenting skills are lacking and there is no extended family support 2. Parenting skills are minimal and there is limited extended family support 3. Parenting skills are apparent but not adequate 4. Parenting skills are adequate 5. Parenting skills are well developed Disabilities 1. In crisis- acute or chronic symptoms affecting housing, employment, social interactions, etc. 2. Vulnerable-sometimes or periodically has acute or chronic symptoms affecting housing, employment, social interactions, etc. 3. Safe- rarely has acute or chronic symptoms affecting housing, employment, social interactions, etc. 4. Building Capacity - asymptomatic - condition controlled by services or medication. 5. Thriving - no identified disability. HiddenTotal ScoreCommentsThis field is for validation purposes and should be left unchanged.
