Initial Questionnaire Assessment PDF

QUESTIONAIRE INSTRUCTIONS: Use this assessment to determine which tier of support you need and what services can help you move forward. How to Calculate Your Score: Add up the numbers for each question. Example: If you scored 4, 5, 3 on three questions, your total score...

QUESTIONAIRE INSTRUCTIONS: Use this assessment to determine which tier of support you need and what services can help you move forward. How to Calculate Your Score: Add up the numbers for each question. Example: If you scored 4, 5, 3 on three questions, your total score would be 12. Total score range is 16-80. Legend for Calculating Your Tier 16–32: Tier 1 (Higher Support) You may need intensive support in foundational areas like basic needs, financial stability, and emotional resilience. Services for you may include Emergency Supply Assistance, Financial Coaching, Basic Mental Health Support. 33–56: Tier 2 (Moderate Support) You’re doing well in some areas but could benefit from additional support to maintain stability and manage stress. Services may include Stress Management Coaching, Career Support, Community Engagement, and Social Support Building. 57–80: Tier 3 (Basic Support) You’re on your way to becoming self-sufficient and stable, but you may need some additional support to optimize your personal growth, career planning, and stress management. Services for you may include Personal Development Coaching, Advanced Career Services, Leadership Skills, and Mental Health Counseling.  QUESTIONAIRE INSTRUCTIONS: While this score can help guide you, it's important to consider your situation holistically. If you score higher in a particular tier but feel that you're doing well in a specific area (such as emotional stability or financial security), you may not need the full level of support. Feel free to adjust your support tier if you feel certain aspects of your life are stable, even though the assessment score suggests higher support.  SURVEY Day Month Year NAME: DATE OF BIRTH: CIVIL STATUS: GENDER: Male Female Not Listed Prefer Not to Answer Unit No. St. No. Street Town/City/Suburb State Zip Code Country ADDRESS: INSTRUCTIONS On a scale of 1 to 5, how satisfied or dissatisfied are you based on each question provided? Neither Satisfied Very Dissatisfied Dissatisfied or Dissatisfied Satisfied Very Satisfied 1 2 3 4 5 1. I feel safe and secure in my current living situation. 2. I have reliable access to food, water, and basic necessities. 3. I have a stable source of income or financial support. 4. I have access to healthcare and can manage my medical needs. 5. I feel emotionally stable and resilient in most situations. 6. I have tools or strategies to manage stress and anxiety.  INSTRUCTIONS On a scale of 1 to 5, how satisfied or dissatisfied are you based on each question provided? Neither Satisfied Very Dissatisfied Dissatisfied or Dissatisfied Satisfied Very Satisfied 1 2 3 4 5 7. I feel that I have support from others (friends, family, community) when I need it. 8. I feel capable of managing my emotions in difficult situations. 9. I have healthy, supportive relationships with family or friends. 10. I have a sense of belonging to a community (in-person or online). 11. I am able to set and maintain healthy boundaries in my relationships. 12. I feel that I can trust others and ask for help when I need it. 13. I feel confident in my ability to make decisions for myself. 14. I am actively working toward personal or professional goals.  INSTRUCTIONS On a scale of 1 to 5, how satisfied or dissatisfied are you based on each question provided? Neither Satisfied Very Dissatisfied Dissatisfied or Dissatisfied Satisfied Very Satisfied 1 2 3 4 5 15. I feel in control of my time and responsibilities. 16. I have a positive vision for my future and take steps toward it.