"Initial Assessment" - Florida

Initial Assessment is a legal document that was released by the Florida Department of Economic Opportunity - a government authority operating within Florida.

Form Details:

  • The latest edition currently provided by the Florida Department of Economic Opportunity;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Economic Opportunity.

ADVERTISEMENT
ADVERTISEMENT

Download "Initial Assessment" - Florida

Download PDF

Fill PDF online

Rate (4.5 / 5) 17 votes
Initial Assessment
Name: _______________________ Last Four SSN: ________________ Date: _______/_______/20
Home Phone Number: ____________________
Cell Number: __________________________________
Emergency Contact Name:_________________ Emergency Contact Number:______________________
Other Contact Number: ____________________ Contact Type: ___________________________________
Address __________________________________________________________________________________
Street
City
State
Zip
Children in the Household
Age
______________________
____
In school?
Yes
No
______________________
____
In school?
Yes
No
______________________
____
In school?
Yes
No
______________________
____
In school?
Yes
No
______________________
____
In school?
Yes
No
How can we help you right now?
I want a job so I can pay the bills
I want to go to school so I can get a better job
I want childcare so I can get a job or go to school
I want childcare for medical appointments
I want help with transportation so I can get a job or go to school
I want help with transportation so I can get to doctor’s appointments and/or therapy appointments
I could use an advocate dealing with my doctor
I want help applying for social security
Other __________________________________________________________________________________
What do you feel are your most pressing needs?
I need to pay my light or utility bill
I need help with rent or I may become homeless
I need to set up childcare
I have a lot of past due bills that are causing problems
I have to go to court
I have to complete community service
I have to meet with my probation officer and that takes a lot of my time
I have fines that I have to pay to get my license back or begin working again
I have a felony charge that I feel keeps me from getting a job
I do not feel safe when I go home
I have no way to get around town
I do not feel safe with my partner
I feel alone and overwhelmed, I would like someone to help me
I want help finding a job
I want help getting back in to school
Welcome to our program. We want to provide you with services so you can begin moving towards a career
you will enjoy and be rewarding.
Our program is designed to help you gain skills you need to start a career you want. What kind of career
are you interested in?
Nursing
Accounting
NOT AN OFFICIAL AWI DOCUMENT.
Initial Assessment
Name: _______________________ Last Four SSN: ________________ Date: _______/_______/20
Home Phone Number: ____________________
Cell Number: __________________________________
Emergency Contact Name:_________________ Emergency Contact Number:______________________
Other Contact Number: ____________________ Contact Type: ___________________________________
Address __________________________________________________________________________________
Street
City
State
Zip
Children in the Household
Age
______________________
____
In school?
Yes
No
______________________
____
In school?
Yes
No
______________________
____
In school?
Yes
No
______________________
____
In school?
Yes
No
______________________
____
In school?
Yes
No
How can we help you right now?
I want a job so I can pay the bills
I want to go to school so I can get a better job
I want childcare so I can get a job or go to school
I want childcare for medical appointments
I want help with transportation so I can get a job or go to school
I want help with transportation so I can get to doctor’s appointments and/or therapy appointments
I could use an advocate dealing with my doctor
I want help applying for social security
Other __________________________________________________________________________________
What do you feel are your most pressing needs?
I need to pay my light or utility bill
I need help with rent or I may become homeless
I need to set up childcare
I have a lot of past due bills that are causing problems
I have to go to court
I have to complete community service
I have to meet with my probation officer and that takes a lot of my time
I have fines that I have to pay to get my license back or begin working again
I have a felony charge that I feel keeps me from getting a job
I do not feel safe when I go home
I have no way to get around town
I do not feel safe with my partner
I feel alone and overwhelmed, I would like someone to help me
I want help finding a job
I want help getting back in to school
Welcome to our program. We want to provide you with services so you can begin moving towards a career
you will enjoy and be rewarding.
Our program is designed to help you gain skills you need to start a career you want. What kind of career
are you interested in?
Nursing
Accounting
NOT AN OFFICIAL AWI DOCUMENT.
Teaching
Childcare
X-Ray Technology
Massage or Physical Therapy
Pharmacy
Food Service
Hospitality
Carpentry, Welding
Clerical
Driving trucks, buses or taxis
Dental Assistant
Computers/Technology
Policy/Detective
Firefighter
Phlebotomist
Other medical
I am not really sure
Other________________________
Do you have a high school diploma or GED?
Yes
No
If no, highest grade completed: __________
Have you ever obtained a certificate for gaining skills on the job or in training?
Yes
No
What was the skill or the training called? ________________________________________________________
Did you enjoy going to school?
Yes
No
What did you like about school? _______________________________________________________________
What did you dislike about school? _____________________________________________________________
Were you ever tested for a learning disability?
Yes
No
If you could go back to school, what type of education or training would you want to enter?
GED
Diploma
College
Clerical (answering phones, typing, medical assistant)
Patient Care/Nursing Certificate
Computers
Childcare or Substitute Teaching
Truck Driving
Dental Assistant
Other
I am not interested in going back to school
Have you applied to go back to school within the last three months?
Yes
No
If yes, where? ______________________________ For what? _______________________________________
Are there circumstances that would prevent you from going to work, going to school or other activities?
Yes
No If yes, Please describe ___________________________________________________________
__________________________________________________________________________________________
a.
Do you have someone to watch your children everyday while you are at work and school?
Yes
No
b.
Would you like childcare so you can go to work and/or school everyday?
Yes
No
c.
If your children are sick, who will take care of your children while you go to work or school?
_____________________________
d.
Do you have to leave work, school or home to deal with your child’s behavior problems on a regular
basis?
Yes
No
If yes, is your child seeing a counselor regularly?
Yes
No
e.
Do you have to leave work, school or home to deal with your child’s health issue on a regular basis?
Yes
No If yes, who will be able to help you while you are working with us? ___________
f.
How will you get to school or work everyday?
Bus
Own car
A ride with friend or family
member
Walk
Taxi
g.
Would you like help paying for transportation?
Yes
No
NOT AN OFFICIAL AWI DOCUMENT.
Do you know what steps you need to take to start your career?
Yes
No If yes, please enter what steps you need to take to start this career: __________________
_________________________________________________________________________________________
Work history provides a lot of great information to help you prepare for work or school. Please take time
to complete the following section of the form
Employer
Phone
Job Title
Employer Address
City, State
Wage (annual or per hour)
No. of Hours Per Week
Start Date/End Date
Reason for Leaving
Job Duties
Employer
Phone
Job Title
Employer Address
City, State
Wage (annual or per hour)
No. of Hours Per Week
Start Date/End Date
Reason for Leaving
Job Duties
Employer
Phone
Job Title
Employer Address
City, State
Wage (annual or per hour)
No. of Hours Per Week
Start Date/End Date
Reason for Leaving
Job Duties
What are other skills that you have? Examples include: caring for children, answering multi-line phones, typing
30 wpm, etc.
NOT AN OFFICIAL AWI DOCUMENT.
Participant Signature:_______________________________________ Date: ________________________
Case Manager Signature: ________________________ Reviewed with customer on: ___________________
NOT AN OFFICIAL AWI DOCUMENT.