Survey – Sabathani Community Center

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Survey

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Self-Sufficiency Matrix

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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 job2 – 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.

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310 East 38th Street
Suite 120
Minneapolis MN 55409

612.821.2308
info@sabathani.org

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