Circles Progress Report
Circle Leader Initials
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Initial of First Name
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Initial of Last Name
Circles ID #
*
Email
*
example@example.com
Circles Location
Circles Essex
Date of Data Collection
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Month
-
Day
Year
Date
Progress Report Period
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Intake
Training Class Completion
6 Months
12 Months
18 Months
24 Months
30 Months
36 Months
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Housing, Transportation, Education, Employment & Support
Is your housing safe and secure for the next three months?
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Yes
No
Please explain.
What is your housing status?
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Rent
Own
Other
Please explain your current housing arrangement.
Do you have any other housing concerns?
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Yes
No
What are your concerns?
Do you have reliable transportation?
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Yes
No
Additional information or transportation concerns:
What is the highest level of formal education you have completed?
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Not Yet Completed High School
GED
High School
Some College
Certification or Technical Training
2-Year Degree
4-Year Degree
Master's Degree or Higher
Have you completed a job readiness training course?
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Yes
No
What is your current employment status?
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Unemployed
Part-Time
Full-Time
Self-employed
Retired
Are you satisfied with your level of employment?
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Yes
No
How many adults (18+) are in your household? Include yourself, your spouse/partner (if applicable) and any adults for which you and your spouse/partner (if applicable) pay 50% or more of their total expenses. Do not include adults that live with you but are self sufficient.
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How many children are in your household? Include children under 18 for which you and your spouse/partner (if applicable) pay 50% or more of their total expenses, even if they reside in another location.
*
Names of other Circle Leaders in your household:
Are you currently matched to Allies?
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Yes
No
How many?
How many people can you count on for support?
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Does this group of people include those who are similar to you or have similar life circumstances (Bonding Social Capital)?
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Yes
No
Does this group of people include those who are different from you and have different life circumstances (Bridging Social Capital?
*
Yes
No
Notes or Concerns on this Section:
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Monthly Income
Income you received last month and total for the last 6 months
Total Monthly Income
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Rows
Last Month’s Income
Total for Last 6 Months
Circle Leader Income
Other Adult Income
Child Support
Social Security
Military Pension
Other Income
Total Income: Last Month
Total Income: Last 6 Mths
If paid by the hour, what is your hourly rate?
About how many hours do you work per week?
*
Amount of Earned Income Tax Credit (EITC) last calendar year? If you did not apply, put 0.
*
Notes or Concerns on Income:
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Debt & Credit Score
Debt
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Rows
Total Debt
(Account Balances)
Monthly Minimum Payment
Credit Cards
Medical
Student Loans
Auto Loans
Other Debt
Total Debt
Total Monthly Debt
Current Credit Score
Choose all that apply:
I do not know my credit score
I do not understand how my credit score affects my economic status
Notes or Concerns on Credit & Debt:
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Cash Assets
Cash Assets
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Rows
Total Amount
Checking
Savings
Cash on Hand
Investments
Total Cash Assets
What is your savings goal?
Notes or Concerns on Cash Assets:
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Monthly Public Benefits
Do you receive housing benefits?
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Yes
No
How much do you receive monthly for housing?
Do you receive food benefits (SNAP or other government funded)?
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Yes
No
How much do you receive monthly for food?
Do you receive healthcare benefits?
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Yes
No
How much do you receive monthly for healthcare?
Do you receive government financial assistance benefits?
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Yes
No
How much do you receive monthly in financial assistance?
Do you receive childcare benefits?
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Yes
No
How much do you receive monthly for childcare?
Do you receive unemployment benefits?
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Yes
No
How much do you receive monthly for unemployment?
How many months have you received unemployment?
Notes or Concerns on Public Benefits:
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Monthly Expenses
Input Monthly "Big 5" Expenses (Housing, Transportation, Food, Childcare, Healthcare)
Housing Expenses
*
Rows
Monthly Expense
Rent or Mortgage
Water
Electric & Gas
Phone
Internet
Insurance
Real Estate Taxes
Total Monthly Housing Expenses
Transportation Expenses
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Rows
Monthly Expense
Car Payment
Estimated Repairs
Gas
Insurance
Bus Fees
Other
Total Monthly Transportation Expenses
Food Expenses
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Rows
Monthly Expense
Groceries (Not Covered by SNAP)
SNAP Benefits Used
Dining Out
Other
Total Monthly Food Expenses
Total Monthly Childcare Expenses
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Healthcare Expenses
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Rows
Monthly Expense
Monthly Insurance Cost
Monthly Copays
Monthly Medication Expenses
Monthly Medical Bills (not covered by insurance)
Total Monthly Healthcare Expenses
Total Monthly "Big 5" Expenses
Notes or Concerns on Expenses:
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Assistance
Do you receive or need emergency food, utility or housing assistance in the last 6 months?
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Yes
No
Did the assistance help you reach a place of economic stability?
Yes
No
Is there a need for assistance at the present time?
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Yes
No
Do you see a need for assistance rising in the future?
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Yes
No
Healthcare
Do you have health insurance for yourself?
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Yes
No
Do all the other adults in your household have health insurance?
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Yes
No
Not Applicable (I am the only adult in my household)
Do all the children in your household have health insurance?
*
Yes
No
Not Applicable (I do not have any children in my household)
Notes or Concerns on Assistance & Healthcare:
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Life Self Assessment Tool
FOOD - Check the option that best describes your current access to food.
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Surviving - I have no food or have difficulty finding food.
Vulnerable - I depend on free food sources such as food pantries.
Stable - I buy my own food but do not usually prepare healthy meals.
Thriving - I buy my own food and prepare healthy meals.
PHYSICAL HEALTH - Check the option that best describes your current physical health.
*
Surviving - I have urgent medical issues that are untreated.
Vulnerable - I have urgent medical issues being addressed by a doctor.
Stable - I have no urgent medical issues, but I do not exercise regularly.
Thriving - I am healthy, have health insurance, and exercise regularly.
MENTAL HEALTH/SUBSTANCE ABUSE - Check the option that best describes your current mental health and/or use of substances.
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Surviving - I have untreated mental health or substance abuse issues.
Vulnerable - I am actively treating mental health or substance abuse issues.
Stable - I have been in good mental health, with no substance abuse, for less than a year.
Thriving - I have been in good mental health, with no substance abuse, for more than a year.
EMOTIONAL OR PHYSICAL ABUSE - Check the option that best describes your current experience with emotional or physical abuse.
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Surviving - I am in an abusive situation. I have no exit strategy.
Vulnerable - I am actively planning to leave an abusive situation.
Stable - I have left an abusive situation and am in recovery.
Thriving - I have lived without abuse for at least a year.
WORK - Check the option that best describes your current job status.
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Surviving - I do not have a job.
Vulnerable - I have a job, but it is temporary, unreliable, or has no potential for advancement.
Stable - I have a reliable job, some skills, and some opportunities to advance.
Thriving - I have a satisfying job, strong skills, and a long-term career path.
Not Applicable - (Retired or other satisfactory source of income)
FINANCES - Check the option that best describes your current financial status.
*
Surviving - My debt and spending feel unmanageable or overwhelming.
Vulnerable - I have debt-repayment and spending plans but don't follow them consistently.
Stable - I consistently follow my plan to pay off debt and build savings.
Thriving - I feel financially secure.
LEGAL- Check the option that best describes your current status with legal issues.
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Surviving - I have legal issues I do not understand or am not able to manage.
Vulnerable - I am addressing legal issues but do not have enough support.
Stable - I am addressing legal issues with support from a lawyer or other knowledgeable person.
Thriving - I am not involved in any legal issues.
CHILDCARE- Check the option that best describes your current access to childcare.
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Surviving - I have no access to childcare.
Vulnerable - I have some childcare, but it's not dependable.
Stable - I have dependable childcare but can only afford it with assistance.
Thriving - I have dependable childcare, and I pay for it myself.
Not Applicable - I do not have children that require childcare.
POWER AND AUTONOMY- Check the option that best describes your current feelings of control over your life.
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Surviving - I feel helpless, like I have no control of my life.
Vulnerable - I am learning to manage situations that used to overwhelm me.
Stable - I am gaining confidence in my ability to set and achieve goals.
Thriving - If I really want something, I will find a way to make it happen.
PURPOSE AND MEANING- Check the option that best describes your current feelings about purpose and meaning in life.
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Surviving - I feel there is no purpose or meaning in my life.
Vulnerable - I think my life has value, but I struggle in finding purpose day-to-day.
Stable - I live with purpose but lack deep and meaningful connections.
Thriving - I participate in a meaningful community that deepens my purpose and values.
Notes or Concerns on the Life Self Assessment:
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