Family Self Sufficiency Intake

Application for the Family Self Sufficiency Program at NW MN Multi-County HRA

Head of Household: Please complete the following information to the best of your ability. This information will be used by the Family Self Sufficiency staff to determine program eligibility and to establish goals that will increase your household's earned income. There are no right or wrong answers.
Date*

MonthDayYear
Date Completing Form
HEAD OF HOUSEHOLD
First Name*
Middle Initial
Last Name*
Birth Date*

MonthDayYear
Date
Last 4 of Social Security Number*
Gender*

MaleUnspecifiedFemale
Veteran Status*

YesRefusedNoUnknown
Race*

WhiteAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderNative American/Alaskan NativeOther
Ethnicity*

Hispanic or LatinoNot Hispanic or Latino
Address*

Street Address

Apt/Unit

CityState

Zip Code
Mailing Address (if different)

Street Address or PO Box Number

Apt/Unit

CityState

Zip Code
Cell Phone
Home Phone
Email Address
example@example.com
Preferred Contact Method(s)*

Phone CallEmailTextMail
Is English your primary language?*

YesNo
If no, what is your primary language?*
Is English your secondary language?*

YesNo
How well do you speak English?*

GreatGoodNot Well
What sources of income does your household receive?*

EmploymentUnemploymentCounty Public Assistance (MFIP, GA, DWP, MSA)Pension/RetirementSocial SecuritySSI/SSDI/RSDIChild SupportVeteran BenefitsOther
Please select your household income level below:*

$0 - $5,000$15,000 - $20,000$30,000 - $35,000$5,000 - $10,000$20,000 - $25,000$35,000 or more$10,000 - $15,000$25,000 - $30,000
BASIC NEEDS/COMMUNITY RESOURCE ASSESSMENT
Are you willing to participate in meetings designed to help you succeed?*

YesNo
Do you have immediate needs?*

YesNo
What immediate needs do you have?*

FoodUtilitiesTransportationCrisis PreventionMedicalDentalVisionClothingOther
Are you currently working with other community programs or agencies?*

YesNo
If yes, what programs or agencies?*
Have you worked with other community programs or agencies in the past?*

YesNo
If yes, what programs or agencies?*
Are you currently receiving any benefits through social services?*

YesNo
What type of benefits? (select all that apply)*

General Assistance (GA)Minnesota Supplemental Aid (MSA)Minnesota Family Investment Program (MFIP)Diversionary Work Program (DWP)Housing Grant (HG)Food Support (SNAP)Medical Assistance (MA)MinnesotaCareChildcare Assistance (CCAP)Energy AssistanceWomen Infant Children (WIC)
Do you have internet access?*

YesNo
Do you have any of the following? (select all that apply)*

Computer/LaptopTabletSmartphoneNone of the above
HEALTH ASSESSMENT
Do you have health insurance?*

YesNo
Type of insurance (select all that apply)*

Medical AssistanceMinnesotaCarePrivate InsuranceMedicareEmployer ProvidedOther
Do you have a primary care physician?*

YesNo
Do you have a dentist?*

YesNo
Does any family member need special assistance due to a disability?*

YesNo
Which family member?*
What is needed?*
Are you currently working with any other agency that provides supportive services?*

YesNo
What agency?*
What services?*
FINANCIAL/CREDIT ASSESSMENT
Do you pay your bills on time?*

YesNo
How would you describe your credit score?*

GreatOKGoodNot GoodFairUnknown
Are you currently using a budget?*

YesNo
Do you have a checking account?*

YesNo
Do you have a savings account?*

YesNo
Do you receive the Earned Income Tax Credit?*

YesNo
Do you have an Individual Development Account?*

YesNo
If yes, what type?*

HomebuyerEducationBusinessOther
Have you ever filed for bankruptcy?*

YesNo
Have you ever owned a home?*

YesNo
Would homeownership be one of your goals?*

YesNo
Would you like assistance with any of the following? (select all that apply)*

BudgetingFinancial CoachingCredit CounselingHomeownershipBuild a SavingsDebt ReductionOther
TRANSPORTATION ASSESSMENT
Do you have a driver's license?*

YesNo
Do you have access to a vehicle?*

YesNo
If yes, are you in need of gas vouchers?*

YesNo
For what type of travel?*

MedicalEducationWork
If you do not have your driver's license or access to a vehicle, what do you use for transportation?*

Public TransportationTaxiUberFriends/FamilyWalk/BikeOther
Do you need help with this transportation?*

YesNo
If yes, for what type of travel?

MedicalEducationWork
EDUCATION ASSESSMENT
Do you have a high school diploma or GED?*

YesNo
If yes, when did you graduate/receive your GED? *

MonthDayYear
Date
High School DiplomaGED
If no, what is the highest grade you have completed?*
Are you currently enrolled in GED, ABE, or high school completion program?*

YesNo
Do you have post-secondary education?*

YesNo
If yes, date completed:*

MonthDayYear
Date
Degree*
Are you currently enrolled in post-secondary education?*

YesNo
What are you studying?*
Name of School*
Estimated Completion Date*

MonthDayYear
Date
How would you assess your skills when it comes to reading?*

ExcellentOkGoodI need help with reading
How would you assess your skills when it comes to math?*

ExcellentOkGoodI need help with math
How would you assess your skills when it comes to writing?*

ExcellentOkGoodI need help with writing
Have you taken English as Second Language classes?*

YesNo
EMPLOYMENT ASSESSMENT
Are you employed?*

Yes, full timeYes, seasonalYes, part timeNo
Are you able to seek and maintain employment?*

YesNo
CURRENTLY EMPLOYED
Name of Employer*
Start Date of Employment: (Month, date, & year)*

MonthDayYear
Date
Amount you make:*
Amount from previous question is:*

HourlyMonthlyWeeklyAnnuallyBi-Weekly
How many hours per week do you work?*
Do you receive benefits?*

YesNo
What type of benefits?*

Health InsuranceDental InsuranceVision Insurance401kOther
Are you satisfied with your current job?*

YesNo
Why or why not?*
Are you looking for a different job?*

YesNo
NOT EMPLOYED
Reason for Unemployment*

Looking for WorkEnrolled in School/Trade ProgramOn DisabilityLaid OffBy ChoiceRetiredQuitFiredOther
When was the last time you were employed?*

MonthDayYear
Date
What was your last job?*
Why did you leave the job?*
What are the average number of years you have been employed in your lifetime?*
HOUSEHOLD EMPLOYMENT
Is anyone else in your household employed?*

YesNo
Who is employed?*
Name of Employer*
How often do they work?*

Full timeSeasonalPart time
Start Date of Employment: (Month, date, & year)*

MonthDayYear
Date
Amount they make:*
Amount from previous question is:*

HourlyMonthlyWeeklyAnnuallyBi-weekly
How many hours per week do they work?*
GENERAL EMPLOYMENT NEEDS/BARRIERS ASSESSMENT
Do you have a resume?*

YesNo
If yes, is it current/up to date?*

YesNo
If no, do you need help creating one?*

YesNo
Do you have professional references?*

YesNo
Do you know how to fill out a job application?*

YesNo
Do you have experience with applying for employment online?*

YesNo
Are you currently receiving assistance with job placement?*

YesNo
If yes, through what agency?*
Do you feel you need additional skills or job training?*

YesNo
If yes, what additional skills do you feel you need? (select all that apply)*

Interviewing SkillsResume SkillsJob Search SkillsJob TrainingInternshipComputer SkillsOther
List any areas of employment that you are specifically interested in doing:*
What steps are you willing to take to get the type of employment listed above?*
What type(s) of work have you done in the past?*
Do you have a certificate in a specialized career field, trade, or vocation?*

YesNo
If yes, please list:*
Would you like to or need to take computer classes?*

YesNo
Do you have basic computer knowledge of the following? (select all that apply)*

TypingMicrosoft OfficeWordExcelPowerPoint
Does anyone else in the household need assistance finding employment?*

YesNo
If yes, who?*
Do you feel your language skills are adequate for the kind of employment you are seeking?*

YesNo
Do you feel you have barriers to obtaining the job or career you want?*

YesNo
If yes, what are the barriers? (select all that apply)*

AgeLack of Work HistoryCriminal HistoryReliable TransportationUnpaid TicketsChildcareLack of EducationNeed of CounselingDisabilityAlcohol or Drug PreventionAppearance/GroomingLong Absence from WorkInadequate ClothingInadequate Career ChoiceOther
Do you have any type of criminal history that is a barrier to getting desired employment?*

YesNo
If yes, please explain:*
YOUTH INFORMATION
Are there children under the age of 18 in your household?*

YesNo
Do you have reliable childcare?*

YesNo
How many children receive childcare?*
Do you have back up childcare?*

YesNo
Do you have children attending school?*

YesNo
If yes, please list name, school name, and grade:*
Do any of your children need extra support with schooling?*

YesNo
If yes, please list who and what they need:*
Do any of your children need after-school care so you can work?*

YesNo
Do you need assistance with activities for your children in the summer?*

YesNo
Do your children need support with high school completion or alternative education resources?*

YesNo
If yes, please explain:*
PERSONAL ASSESSMENT
What are your most significant accomplishments?*
What are some disappointments you have experienced in life?*
What is one achievement that makes you proud? (Not a person or people )*
List your top 3 strengths:
Strength #1*
Strength #2*
Strength #3*
List your top 3 strengths:*
You are happiest when you:*
You feel lowest when you:*
What are your long term goals over the next five years?*
What has hampered you from achieving the above goals?*
How do you plan to reach your long term goals?*
What is one thing you need to do to be financially secure, in your life now and in the future?*
Please explain why you would like to participate in the Family Self Sufficiency Program:*
Please select 5 (five) of the following goals you are interested in achieving:*

Obtain EmploymentIncrease EmploymentMaintain EmploymentHomeownershipFinancial Self Sufficiency (Elimination of Public Assistance)Increase Earned Income by at least 25%Reduction or elimination of Section 8 Housing Assistance
Please select items below for interim goals. These items will help you reach the 5 goals you selected above. (select all that apply)*

Job TrainingObtain EmploymentEducation - Participate in High School or GED ProgramObtain a College DegreeObtain a Certificate from a Business or Trade SchoolCareer CounselingHomeownership CounselingEnglish as a Second Language ClassesBudgeting/Credit Counseling/Financial Literacy
On a scale of 1 to 10, with 10 being the highest, select the number that represents how you would describe yourself: I am optimistic*

12345678910
On a scale of 1 to 10, with 10 being the highest, select the number that represents how you would describe yourself: I am satisfied with my life.*

12345678910
On a scale of 1 to 10, with 10 being the highest, select the number that represents how you would describe yourself: I am satisfied with my health.*

12345678910
On a scale of 1 to 10, with 10 being the highest, select the number that represents how you would describe yourself: I am satisfied with my financial situation.*

12345678910
On a scale of 1 to 10, with 10 being the highest, select the number that represents how you would describe yourself: I am satisfied with my social life.*

12345678910
On a scale of 1 to 10, with 10 being the highest, select the number that represents how you would describe yourself: I feel good about my personal relationships.*

12345678910
PERSONAL NEEDS

Please check items below that you consider to be something that you need help with: (select all that apply)
Educational Needs*

GEDTech or Trade SchoolCollege (bachelor's or master's degree)Graduate SchoolReading SkillsMath SkillsWriting SkillsComputer SkillsAdult Basic EducationEnglish as a Second Language ClassNone/Not Applicable
Employment Needs*

Job Readiness/TrainingJob SearchPart-Time EmploymentFull-Time EmploymentCareer Planning/ExplorationCareer AdvancementCareer CounselingInterview/Work ClothingNone/Not Applicable
Financial Needs*

Debt RecoveryMoney ManagementCreating a BudgetHomeownershipFinancial CounselingBuilding a Savings/RetirementNone/Not Applicable
Legal Needs*

DivorceFamily CourtChild SupportCriminal Record HistoryNone/Not Applicable
Transportation Needs*

Obtain Driver's LicenseReinstate Driver's LicenseObtain a VehicleObtain Reliable TransportationVehicle RepairsPoor Driving RecordObtain Vehicle InsuranceTransportation AssistanceNone/Not Applicable
Children/Childcare/Parenting Needs*

Need ChildcareCurrent Childcare is IrregularCurrent Childcare is UnreliableNeed Head Start PlacementNeed After School CareNeed to Enroll in SchoolHelp with DisciplineHomework HelpIncreasing PatienceBuilding a Better Relationship with ChildrenParenting EducationPregnancy Education/ClassesChild Development EducationNone/Not Applicable
Personal Growth and Development Needs*

Stress ManagementTime ManagementProblem SolvingOrganizational SkillsDecision MakingSelf EsteemHelp with Family ProblemsNone/Not Applicable
HEALTH TOOLS
Do you have a disability as defined by the American with Disabilities Act and determine by a physician, Medicaid, or other authority?*

YesNo
What type of disability category do you have?*

Physical DisabilityBoth Physical & MentalMental DisabilityRefusedUnknown
Do you have a need for assistance with activities of daily living? (grooming, bathing, home management, etc)*

YesNo
Activities of Daily Living (ADL) - Select all that apply*

Ambulation/LocomotionFeeding or EatingToiletingBathingGroomingTransferringDressingNot Applicable
Instrumental Activities of Daily Living (IADL) - Select all that apply*

Handling TransportationManaging MedicationsUsing the PhoneHousekeeping/Basic Home MaintenancePreparing MealsOperating Home EquipmentManage Money/Sorting Paperwork (bills)ShoppingNot Applicable
Have you received a routine medical examination in the past 12 months?*

YesNo
Month & Year of last Medical Examination*

MonthYear
Have you received a routine dental examination in the past 12 months?*

YesNo
Month & Year of last Dental Examination*

MonthYear
Are you currently being treated for substance abuse or dependence, or have you been treated in the past 12 months?*

Currently Being TreatedTreated in the Past 12 MonthsNo/Never Been Treated
Date of Last Treatment*

MonthDayYear
Date
Should be Empty:

Application for the Family Self Sufficiency Program at NW MN Multi-County HRA

HEAD OF HOUSEHOLD

BASIC NEEDS/COMMUNITY RESOURCE ASSESSMENT

HEALTH ASSESSMENT

FINANCIAL/CREDIT ASSESSMENT

TRANSPORTATION ASSESSMENT

EDUCATION ASSESSMENT

EMPLOYMENT ASSESSMENT

GENERAL EMPLOYMENT NEEDS/BARRIERS ASSESSMENT

YOUTH INFORMATION

PERSONAL ASSESSMENT

List your top 3 strengths:

PERSONAL NEEDS

HEALTH TOOLS