Stepping Stones to Success

Goal4 It!TM for CCMEP
Stepping Stones to Success
MY NAME*
DATE*

MonthDayYear
Date
Signature*

Clear
Phone Number*
Please enter a valid phone number.
Question 1 What is your overall stress level right now*

I am very stressI am mostly stressedI am stressedI am moderately stressedI am not stressed at all
Question 2 Where do you feel you currently are in these areas of life? (Fill in a circle in each pathway row)
Housing (from I do not have housing or my housing is unsafe to I have stable and safe housing)*

Area of significant needArea of needStable, but could improveThriving
Transportation (from I have no transportation to I have reliable transportation and a back up plan)*

Area of significant needArea of needStable, but could improveThriving
Personal Well-Being (from my personal well-being or my mental health needs my attending to I am doing well, am mentally healthy and am fully able to work)*

Area of significant needArea of needStable, but could improveThriving
Family Well-Being (from family challenges interfere with my progress, or I have no child care to My family is well, and I have safe, reliable child care (as needed))*

Area of significant needArea of needStable, but could improveThriving
Social Support (from I don't have any friends to I have good friends I can trust)*

Area of significant needArea of needStable, but could improveThriving
Financial Health (from I do not have enough money to cover my basic needs to I have enough money to cover my basic needs and am able to save some money too.)*

Area of significant needArea of needStable, but could improveThriving
Legal (from My legal history or involvement with the court system is holding me back to I have no current legal issues)*

Area of significant needArea of needStable, but could improveThriving
Education and Training (from my education is off-track and I don't know how to get it back on track to my education is on track and I am gaining the skills I need)*

Area of significant needArea of needStable, but could improveThriving
Career Path (from I don't know what my career path looks like, where to start, or have experience to I know what I want my career path to look like and I am making progress towards it.)*

Area of significant needArea of needStable, but could improveThriving
Question 3 What do you hope to get out of this program and what is your hope for today's meeting?*
Question 4 Do you need to update any information (Example, address, phone number, email, employment etc.)
Question 5 Prior work experience (includes military or volunteer experience) If YES, please describe.*

YesNo
If YES, please describe.
Question 6 What is your current level of education?*
Question 7 Do you have transportation, child care, housing, clothing and other supports needed to enter your chosen career*

YesNo
If No, what do you need help with?
Question 8 What interests you?*
Question 9 What skills or talent do you have?*
Question 10 What are your strengths?*
Question 11 What careers are you interested in?*
Stepping Stones to Success - Release of Information

I give my approval for Ohio Job and Family Services (JFS) staff, Ohio Means Jobs Center staff, and partner agencies to exchange and disclose necessary information about me for services to be provided to me by all programs administered via the JFS, Ohio Means Jobs Center and/or partner agencies. I attest that the information stated above is true and accurate, and I understand that the above information, if misrepresented or incomplete, may be grounds for immediate termination of services and/or penalties as specified by law.
Participant Signature*

Clear
Date*

MonthDayYear
Date
Parent or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Note: As part of the new CCMEP program(s) in which you are participating, JFS is working with an independent evaluator (Ohio State University) to study the effectiveness of the program(s) and services being offered and to learn more about employment outcomes, including job placement. Ohio State University may contact you to gather information about your occupation, wages, working hours, and other feedback. The purpose of this contact will be to help JFS improve its program(s) and services. Your participation in the evaluation will be voluntary and any personal, identifying information about you that is obtained or shared by Ohio State University will be kept confidential.
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Goal4 It!TM for CCMEP

Stepping Stones to Success