Self Sufficiency Matrix Name First Middle Last Email* Housing1. Homeless or threatened with eviction2. 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 adequate4. Household is in safe, adequate subsidized housing5. Household is safe, adequate, unsubsidized housingEmployment1. No job2. Temporary, part-time or seasonal; inadequate pay, no benefits3. Employed full time; inadequate pay; few or no benefits4. Employed full time with adequate pay and benefits5. Maintains permanent employment with adequate income and benefitsIncome1. No income2. Inadequate income and/or spontaneous or inappropriate spending3. Can meet basic needs with subsidy; appropriate spending4. Can meet basic needs and manage debt without assistance5. Income is sufficient, well managed; has discretionary income and is able to saveFood1. No food or means to prepare it. Relies to a significant degree on other sources of free or low-cost food2. Household is on food stamps3. Can meet basic food needs, but requires occasional assistance4. Can meet basic food needs without assistance5. Can choose to purchase any food household desiresChildcare (0=n/a)1. Needs childcare, but none is available/accessible and/or child is not eligible2. Childcare is unreliable or unaffordable, inadequate supervision is a problem for childcare that is available3. Affordable subsidized childcare is available, but limited4. Reliable, affordable childcare is available, no need for subsidies5. Able to select quality childcare of choiceChildren’s Education (0=n/a)1. One or more eligible children not enrolled in school2. All eligible children enrolled in school, but one or more children not attending classes3. Enrolled in school, but one or more children only occasionally attending classes4. Enrolled in school and attending classes most of the time5. All eligible children enrolled and attending on a regular basis and making progressAdult Education1. Literacy problems and/or no high school diploma/GED are serious barriers to employment2. Enrolled in literacy and/or GED program and/or has sufficient command of English to where language is not a barrier to employment3. Has high school diploma/GED4. Needs additional education/training to improve employment situation and/or to resolve literacy problems to where they are able to function effectively in society5. Has completed education/training needed to become employable. No literacy problemsLegal1. Current outstanding tickets or warrants or other serious unresolved legal issues2.Current charges/trial pending; noncompliance with probation/parole; legal issues impacting housing qualifications3. Fully compliant with probation/parole terms; past non-violent felony convictions; working on plan to resolve other legal issues4. Has successfully completed probation/parole within past 12 months, no new charges filed; recently resolved other legal issues5. No active legal issues in more than 12 months and/or no felony/significant legal/criminal historyHealth Care1. No medical coverage with immediate need2. No medical coverage and great difficulty accessing medical care when needed. Some household members may be in poor health3. Some members (e.g. children) on Medi-Cal, but adults lack coverage4. All members can get medical care when needed, but may strain budget5. All members are covered by affordable, adequate health insurance Life Skills1.Unable to meet basic needs such as hygiene, food, activities of daily living2. Can meet a few but not all needs of daily living without assistance3. Can meet most but not all daily living needs without assistance4. Able to meet all basic needs of daily living without assistance5. Able to provide beyond basic needs of daily living for self and family Mental Health1. Danger to self or others; recurring suicidal ideation; experiencing severe difficulty in day-to-day life due to psychological problems2. Recurrent mental health symptoms that may affect behavior, but not a danger to self/others; persistent problems with functioning due to mental health symptoms3. Mild symptoms may be present but are transient; only moderate difficulty in functioning due to mental health problems4. Minimal symptoms that are expectable responses to life stressors; only slight impairment in functioning5. Symptoms are absent or rare; good or superior functioning in wide range of activities; no more than every day problems or concerns Substance Abuse1. Meets criteria for severe abuse/dependence; resulting problems so severe that institutional living or hospitalization may be necessary2. 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 activities3. 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 month4. 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 use5. No drug use/alcohol abuse in last 6 months Family Relations1. Lack of necessary support form family or friends; abuse (DV, child) is present or there is child neglect2. 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 neglect3. Some support from family/friends; family members acknowledge and seek to change negative behaviors; are learning to communicate and support4. Strong support from family or friends. Household members support each other’s efforts5. Has healthy/expanding support network; household is stable and communication is consistently open Mobility1. No access to transportation, public or private; may have car that is inoperable2. Transportation is available (including bus), but unreliable, unpredictable, unaffordable; may have care but no insurance, license, etc3. Transportation is available (including bus) and reliable, but limited and/or inconvenient; drivers are licensed and minimally insured4. Transportation (including bus) is generally accessible to meet basic travel needs5. Transportation is readily available and affordable; car is adequately insured Community Involvement1. Not applicable due to crisis situation; in “survival” mode2. Socially isolated and/or no social skills and/or lacks motivation to become involved3. Lacks knowledge of ways to become involved or new to community4. Some community involvement (church, advisory group, support group), but has barriers such as transportation, childcare issues5. Actively involved in community (church, etc.) Safety1. Home or residence is not safe, lethality is high2. Safety is threatened, temporary protection is available, lethality is high3. Safety is minimally adequate, safety planning is essential4. Home is safe, however, future is uncertain, safety planning is important5. Home is apparently safe and stable Parenting Skills (0=n/a)1. Parenting skills are lacking and there is no extended family support2. Parenting skills are minimal and there is limited extended family support3. Parenting skills are apparent but not adequate4. Parenting skills are adequate5. Parenting skills are well developed Disabilities1. 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.Total ScoreEmailThis field is for validation purposes and should be left unchanged.