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/ Survey
Self-Sufficiency Matrix
Contact Details
First Name
Last Name
Email
For each of the following areas of life, choose the selection that best describes your current situation, on the scale of 1 to 5, with 1 being the most in crisis and 5 being the most empowered:
1 = in crisis
2 = vulnerable
3 = safe
4 = building capacity
5 = empowered
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 benefits
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 – Employee full time with adequate subsidized housing.
5 – Maintain permanent employment with adequate income and benefits.
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.
Food
1 – No food or means to prepare it. Rely 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
(if applicable)
1 – Need 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.
Safety
1 – Environment is not safe; immediate level of risk is extremely
high; possible CPS or police involvement.
2 – Safety is threatened, but temporary protection is available; level of risk is high.
3 – Current level of safety is minimally adequate; ongoing safety planning is essential.
4 – Environment is safe, but future safety is uncertain; however, future of such is
uncertain; safety planning is important.
5 – Environment is apparently safe and stable.
Parenting Skills
(if applicable)
1 – There are safety concerns regarding parenting skills; abuse is present.
2 – Parenting skills are minimal; does not relate well with child(ren); potential for abuse or neglect.
3 – Parenting skills are apparent but not adequate; I acknowledge and seek to change negative behaviors; am learning to
communicate and support.
4 – Parenting skills are adequate; support my child(ren)’s efforts.
5 – Parenting skills are well-developed; parent-child relationship(s) is stable and communication is consistently open.
Children’s Education
(if applicable)
1 – One or more eligible children not enrolled in school.
2 – One or more eligible children enrolled in school, but 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
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 – Have high school diploma/GED
4 – Needs additional education/training to improve employment situation and/or resolve literacy problems to where they are able to function effectively in society.
5 – Have completed educational/training needed to become employable. No literacy problems.
Legal
1 – Current outstanding tickets or warrants.
2 – Current charges/trial pending, noncompliance with probation/parole.
3 – Fully compliant with probation/parole terms.
4 – Have successfully completed probation/parole within past 12 months, no new charges filed.
5 – No active criminal justice involvement in more than 12 months and/or no felony 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 AHCCCS)
4 – All members can get medical care when needed but may strain budget.
5 – All members are covered by affordable, adequate health insurance.
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.
4 – Some community involvement (advisory group, support group) but has barriers such as transportation, childcare issues.
5 – Actively involved in community.
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 response 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 everyday problems or concerns.
Contact Information
