ࡱ                >  	                                          %`	                  bjbjٕ                  	 *    W      a                                                              `      `  `      `                                     M      M      M  8   @M  \   M          g    O    @R  (   hR      hR      hR      {S  4  T     SU  T   f      g       g       g       g       g       g  $   i  h  k     $g                           U                      wS     {S      U      U      $g              `      `      hR              hR    9g     OW      OW      OW      U  ^   `  8   hR            hR      f              OW                                                      U      f              OW      OW  r   R\  T                                                                      \      hR      O     @OLl        M      V  ^   \             \  
  Og  0   g      \     /l      cV     /l     \                                                                              /l                    \  8   U      U      OW      U      U                                      U      U      U      $g      $g                                      V  ^                                   U      U      U      g      U      U      U      U                            DF  M                        M                        `      `      `      `      `      `                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Life Skills Strengths Needs Assessment Reporting FormYouth's Name:Date:Worker's Name:STRENGTHSNEEDSSpecial Interests/ ActivitiesFree time activities:Would like more opportunity/time to do or to learn:Clubs or Organizations:Clubs or Organizations:EducationSchool/Highest Grade or Level:Subjects/aspects of school needing work:Best Part of school/Favorite subjects/favorite teachers:Help needed with current educational goals:Languages:Languages:Current educational goals:Help needed with future educational goals:EmploymentWork experience:Current job interest:Has the following:  (Please Check) FORMCHECKBOX   alarm clock FORMCHECKBOX   calendar FORMCHECKBOX   ability to get up on time FORMCHECKBOX   resumeNeeds the following: (Please Check) FORMCHECKBOX   alarm clock FORMCHECKBOX   calendar FORMCHECKBOX   ability to get up on time FORMCHECKBOX   resume FORMCHECKBOX   birth certificate FORMCHECKBOX   social security card FORMCHECKBOX   working papers FORMCHECKBOX   non-driver's license FORMCHECKBOX   birth certificate FORMCHECKBOX   social security card FORMCHECKBOX   working papers FORMCHECKBOX   non-driver's licenseFamily/FriendsFamily members:Relationship with family members:Family Involvement:Relationships with friends:Friends:Needs around beginning, ending or managing special/dating relationships:Other needs:Social/PersonalThings I like about myself:Things about myself I would like to change:Comfortable with: FORMCHECKBOX   meeting new people FORMCHECKBOX   speaking up for myself at home FORMCHECKBOX   speaking up for myself at shool/work FORMCHECKBOX   speaking up for myself with friendsWould like to be more comfortable with: FORMCHECKBOX   meeting new people FORMCHECKBOX   speaking up for myself at home FORMCHECKBOX   speaking up for myself at shool/work FORMCHECKBOX   speaking up for myself with friendsAnger ManagementAnger ManagementStress ManagementStress ManagementMoney ManagementDay-to day money management experiences:Help needed with day-to-day money management practices:Have you ever: FORMCHECKBOX   purchased a money order? FORMCHECKBOX   written a check? FORMCHECKBOX   opened a bank account? FORMCHECKBOX   saved money for something big? FORMCHECKBOX   filed income taxes? FORMCHECKBOX   paid your own bills? FORMCHECKBOX   made out a budget?Learn more about how to: FORMCHECKBOX   purchase a money order? FORMCHECKBOX   writte a check? FORMCHECKBOX   open a bank account? FORMCHECKBOX   save money for something big? FORMCHECKBOX   file income taxes? FORMCHECKBOX   pay my own bills? FORMCHECKBOX   make out a budget?HealthHealth status:Health needs/concerns:Last visit to the doctor:Last visit to dentistMedications:Medications:Physical exercise/weight:Physical exercise/weight:Have you ever: FORMCHECKBOX   called for an appointment? FORMCHECKBOX   used a thermometer? FORMCHECKBOX   taken a first aid course? FORMCHECKBOX   taken a CPR course? FORMCHECKBOX   learned about BC and STD's? FORMCHECKBOX   used birth control? FORMCHECKBOX   gotten your medical history?Would like to learn more about:  FORMCHECKBOX   calling  for an appointment? FORMCHECKBOX   using a thermometer? FORMCHECKBOX   taking a first aid course? FORMCHECKBOX   taking a CPR course? FORMCHECKBOX   learning about BC and STD's? FORMCHECKBOX   using birth control? FORMCHECKBOX   getting your medical history?Personal Appearance/HygieneLearn more about Personal Appearance/HygieneHousingPlans for living independently:Areas to explore:The best/worst aspect of living on your own:Assistance needed with:Accomplishments that will make it easier to move out:Things to accomplish before moving out:TransportationCurrent methods of transportation:Current transportation needs:Plans for transportation later:Assistance needed with future transportation plans:Have you ever: FORMCHECKBOX   taken driver's education? FORMCHECKBOX   obtained a driver's license?  Interested in: FORMCHECKBOX   taking driver's education? FORMCHECKBOX   getting a driver's license?  OtherPAGE  1PAGE  1Dorothy I. Ansell and Joan M. Morse, 1996		CD-97 (4/2008)                                                                                                                                                                                                                                                                                                                                        7  h  i  {            '	  -	  4	  >	  	  	  
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                ,  žžꜪz           j  h$ UmH nH u  j\  h$ UmH nH u j    h$ UmH nH u h$ mH nH uh  h(8P h$  h(8P h(8P  h(8P  h 5CJ OJ QJ h$ 5CJ OJ QJ h$ 5CJ  OJ QJ h$  
h$ CJ  h$ 5CJ$ OJ QJ  .   6  7  E  F  L  M                          ~            ~            s            ~                                                                                                                                          $x $If   a$  x $If   l  kd    $$If   l 4             <' '      	
     % 0                                         4 
l a  f4p
     %   $x x $If   a$    W                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              M  N  O  P  Q  9            3            3            3                                            $If     kd   $$If   l 4            \ T.<'       * 
    	(     %      %      %      % 0                                            4 
l a  f4p(     %      %      %      %  Q  R  a  b  c  X            R            R            R                                                                                                          $If     kd`  $$If   l             yF <' 8   8 8  	     %      %      % 0                                      4 
l a  p     %      %      %  c  d  e  f  g  Z            T            T            T                                                                                                              $If     kd  $$If   l             F <' t      8    	     %      %      % 0                                            4 
l a  p     %      %      %  g  h  i  s  t  z  Z            X            K            K            K                                                                           $x x $If   a$     kd  $$If   l             F <' 8     8   8    	     %      %      % 0                                               4 
l a  p     %      %      %  z  {                                    J            B            B            B                                        x $If   J  kdv  $$If   l 4 <' '                	
     %                   4 
l a  f4p
     %   $x x $If   a$ ]  kd  $$If   l F <' 8                 8                 8                                                          4 
l a                                                                                                                                                                                                                                                                       	  $If   gd(8P   $If    ]  kd  $$If   l F HV<'                                                                                             4 
l a   
            	                                                  =                                         ]  kd  $$If   l F HV<'                                                                                             4 
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  $$If   l F HV<'                                                                                             4 
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  $$If   l F HV<'                                                                      4 
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  x x $If    :  kd[(  $$If   l 4 <' '                                  4 
l a  f4	  $$If   a$ ]  kd'  $$If   l F HV<'                                                                      4 
l a                        "  #  1  2  3  I  J  X  Y  Z  q  r                                       n                      jN,  h$ UmH nH u  j+  h$ UmH nH u h$   jd+  h$ UmH nH u  j*  h$ UmH nH u  jz*  h$ UmH nH u  j*  h$ UmH nH u  j)  h$ UmH nH u h$ mH nH uj    h$ UmH nH u'"  I  q            '  X  ~                                                                                                                                                                                                      $x x $If   a$ ]  kd
/  $$If   l F HV<'                                                                                             4 
l a  
  x x $If     x $If          '  (  6  7  8  X  Y  g  h  i  ~                                      <  >            ضإؔؐtc     j4  h$ UmH nH u h(8P h$ CJ OJ  QJ   h(8P  h$ 5CJ OJ QJ h$   j.  h$ UmH nH u  j.  h$ UmH nH u  j-  h$ UmH nH u  j6-  h$ UmH nH u h$ mH nH uj    h$ UmH nH u  j,  h$ UmH nH u&                                                                  O            I            I            I                    $If    ]  kd/  $$If   l F HV<'                                                                                             4 
l a    x $If   J  kd/  $$If   l 4 <' '                	
     %                   4 
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     %                          !                                                                                                                                                                                                                                                  ]  kdb0  $$If   l F HV<'                                                                        4 
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        '                                     4 
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  x x $If    `  kdA4  $$If   l F HV<'                               '  $                                  4 
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l a  yt(8P  	                                                                          E                                            J  kd<  $$If   l 4 <' '                	
     %                   4 
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     %   $x x $If   a$    `  kdP<  $$If   l F HV<'                               '  $                                  4 
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 ! $If     $If    ]  kdc=  $$If   l F HV<'                                                                                             4 
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        `  o  p  ~                                        <  B  G  I  J  P  W  X  Z  ҳҢґҀujf^Z h  j    h Uh(8P  h$ 5CJ OJ QJ h 5CJ OJ QJ  jD  h$ UmH nH u  jDD  h$ UmH nH u  jC  h$ UmH nH u  jXC  h$ UmH nH u j    h$ UmH nH u h$ mH nH uh$  h(8P h(8P CJ OJ  QJ   h(8P CJ OJ  QJ   h$ CJ OJ  QJ  #        !  U  V  W                                                  =                                         ]  kd:B  $$If   l F HV<'                                                                                             4 
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     % $$If     !v h5 55*5
#v #v#v*#v
:V l 4	(     %      %      %      % 0                                   5 55*5
/ /      /     //////     4    f4p(     %      %      %      % ;$$If     !v h5 85858#v 8:V l y	     %      %      % 0                                   5 8/      // / / //     4    p     %      %      % E$$If     !v h5 t558#v t#v#v8:V l 	     %      %      % 0                                   5 t558/ /      ///     /     4    p     %      %      % 7$$If     !v h5 85858#v 8:V l 	     %      %      % 0                                   5 8/      // / //     /     4    p     %      %      % W $$If     !v h5 85858#v 8:V l     5 84    l $$If     !v h5 '#v ':V l 4	
     %     5 '4    f4p
     % s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    s $$If     !v h5 55#v #v#v:V l     5 554    s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    s $$If     !v h5 55#v #v#v:V l     5 554    l $$If     !v h5 '#v ':V l 4	
     %     5 '4    f4p
     % s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    s $$If     !v h5 55#v #v#v:V l     5 554    s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    ~ $$If    !v h5 55#v #v#v:V l     5 554    a yt(8P  $$If    !v h5 55#v #v#v:V l     5 55/      //     4    a yt(8P ~ $$If    !v h5 55#v #v#v:V l     5 554    a yt(8P ~ $$If    !v h5 55#v #v#v:V l     5 554    a yt(8P  $$If    !v h5 55#v #v#v:V l     5 55/      //     4    a yt(8P ~ $$If    !v h5 55#v #v#v:V l     5 554    a yt(8P w $$If    !v h5 '#v ':V l 4	
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     %     5 '4    a f4p
     % yt(8P ~ $$If    !v h5 55#v #v#v:V l     5 554    a yt(8P  $$If    !v h5 55#v #v#v:V l     5 55/      //     4    a yt(8P s $$If     !v h5 55#v #v#v:V l      5 554     $$If     !v h5 55#v #v#v:V l      5 55/      //     4    s $$If     !v h5 55#v #v#v:V l      5 554     $$If     !v h5 55#v #v#v:V l s     5 55/      //     4     $$If     !v h5 55#v #v#v:V l F      5 55/     4    l $$If     !v h5 '#v ':V l 4	
     %     5 '4    f4p
     % w $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    s $$If     !v h5 55#v #v#v:V l     5 554    t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 3                         t   D                                                               e     C h e c k 4                         t   D                                                               e     C h e c k 1                         t   D                                                               e     C h e c k 2                         t   D                                                               e     C h e c k 3                         t   D                                                               e     C h e c k 4                         s $$If     !v h5 55#v #v#v:V l     5 554    s $$If     !v h5 55#v #v#v:V l     5 554    s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    yt(8P y $$If     !v h5 55#v #v#v:V l     5 554    yt(8P  $$If     !v h5 55#v #v#v:V l     5 55/      //     4    l $$If     !v h5 '#v ':V l 4	
     %     5 '4    f4p
     % s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    M $$If     !v h5 '#v ':V l 4    5 '4    f4t   D                                                               e     C h e c k 5                         t   D                                                               e     C h e c k 6                         t   D                                                               e     C h e c k 7                         t   D                                                               e     C h e c k 8                         t   D                                                               e     C h e c k 9                         v   D                                                               e     C h e c k 1 0                         v   D                                                               e     C h e c k 1 1                         t   D                                                               e     C h e c k 5                         t   D                                                               e     C h e c k 6                         t   D                                                               e     C h e c k 7                         t   D                                                               e     C h e c k 8                         t   D                                                               e     C h e c k 9                         v   D                                                               e     C h e c k 1 0                         v   D                                                               e     C h e c k 1 1                         s $$If     !v h5 55#v #v#v:V l     5 554    l $$If     !v h5 '#v ':V l 4	
     %     5 '4    f4p
     % s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4     $$If     !v h5 55#v #v#v:V l z    5 55/      /4     $$If     !v h5 55#v #v#v:V l     5 55/      /4    y $$If     !v h5 55#v #v#v:V l '$ 5 554    yt(8P  $$If     !v h5 55
#v #v#v
:V l '  5 55
/      //     4    yt(8P } $$If     !v h5 55#v #v#v:V l  '$ 5 554    yt(8P y $$If     !v h5 55#v #v#v:V l '$ 5 554    yt(8P  $$If     !v h5 55#v #v#v:V l '$ 5 55/      //     4    yt(8P v   D                                                               e     C h e c k 1 2                         v   D                                                               e     C h e c k 1 3                         v   D                                                               e     C h e c k 1 4                         v   D                                                               e     C h e c k 1 5                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 8                         v   D                                                               e     C h e c k 1 2                         v   D                                                               e     C h e c k 1 3                         v   D                                                               e     C h e c k 1 4                         v   D                                                               e     C h e c k 1 5                         v   D                                                               e     C h e c k 1 6                         v   D                                                               e     C h e c k 1 7                         v   D                                                               e     C h e c k 1 8                         y $$If     !v h5 55#v #v#v:V l '$ 5 554    yt(8P y $$If     !v h5 55#v #v#v:V l '$ 5 554    yt(8P  $$If     !v h5 55#v #v#v:V l '$ 5 55/      //     4    yt(8P l $$If     !v h5 '#v ':V l 4	
     %     5 '4    f4p
     % s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    s $$If     !v h5 55#v #v#v:V l     5 554     $$If     !v h5 55#v #v#v:V l     5 55/      //     4    x $$If    !v h5 55#v #v#v:V l     5 554    a  $$If    !v h5 55#v #v#v:V l     5 55/      //     4    a q $$If    !v h5 '#v ':V l 4	
     %     5 '4    a f4p
     % x $$If    !v h5 55#v #v#v:V l     5 554    a  $$If    !v h5 55#v #v#v:V l     5 55/      //     4    a x $$If    !v h5 55#v #v#v:V l     5 554    a  $$If    !v h5 55#v #v#v:V l     5 55/      //     4    a v   D                                                               e     C h e c k 1 9                         v   D                                                               e     C h e c k 2 0                         v   D                                                               e     C h e c k 1 9                         v   D                                                               e     C h e c k 2 0                         x $$If    !v h5 55#v #v#v:V l     5 554    a x $$If    !v h5 55#v #v#v:V l     5 554    a q $$If    !v h5 '#v ':V l 4	
     %     5 '4    a f4p
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l a      ( k  (           N o   L i s t         4  @  4           F o o t e r      !   . )@ .           P a g e   N u m b e r     : B@ :          	 B o d y   T e x t      CJ$ OJ QJ D P@ "D           B o d y   T e x t   2     $a$ CJ$ OJ QJ 4 @ 24        H e a d e r      !   H   BH   (8P    B a l l o o n   T e x t      CJ OJ QJ ^J aJ                                                                               6   7   E   F   L   M   N   O   P   Q   R   a   b   c   d   e   f   g   h   i   s   t   z   {                                                                   %  &  '  (  )  *  +  ,  -  .  /  0  1  2  3  4  >  ?  ^  _                                                               
      !  "  #  $  %  &  '  (  )  *  +  ,  -  .  /  0  K  L  w  x  y  z  {  |  }  ~                                            J  d  e              1  Y  {              <  =  >  M  N  ^  _                                                                                    )  *  +  ,  -  .  ;  <  =  >  ?  @  A  B  C  D  T  U  q  r                                                    U            E  |  }  ~                                                                              	   	  X	  Y	  Z	  [	  \	  ]	  ^	  _	  `	  a	  b	  c	  d	  e	  f	  g	  v	  	  	  	  "
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     0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                        0                      0                      0                      0                      0                      0                      0                      0                     0                     0                     0                     0                      0                      0                      0                      0                      0                      0                      0                      0                 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     0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                      0                        0                        0                        0                      0                      0                      0                      0                      0                 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                                  .  [  	  	  	  
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  
        J  q                W  W  Y  Y  Z  Z  \  ]  _  `  b  c                           W  W  Y  Y  Z  Z  \  ]  _  `  b  c                               L  O  W  W  Y  Y  Z  Z  \  ]  _  `  b  c  m  n                                       W  W  Y  Y  Z  Z  \  ]  _  `  b  c                        \F*	 	                 p-ʦ  AEH.5P  >F'i 	                                          h h^h`   .              h          ^`   .              h         ^`OJ QJ o(  o             h         pL p^p`L  .              h         @ @^@`  .             h          ^`  .             h         L ^`L  .              h          ^`  .             h          ^`  .             h         PL P^P`L  .              h          ^`   .             h          ^`  .             h         pL p^p`L  .              h         @ @^@`  .             h          ^`  .             h         L ^`L  .              h          ^`  .             h          ^`  .             h         PL P^P`L  .                          h h^h`   .    p-            AEH            \F*	            >F'i                                                      $  ?5 (8P wTl  `     6   7   E   F   L   M   N   O   P   Q   R   a   b   c   d   e   f   g   h   i   s   t   z   {                                                 %  &  -  .  /  0  1  2  3  4  >  ?  ^  _                                      
      !  "  )  *  +  ,  -  .  /  0  K  L  w  x                              d  e          =  >  M  N  ^  _                                            +  ,  -  .  B  C  D  T  U  q  r                          |  }                                                	   	  X	  Y	  `	  a	  d	  e	  f	  g	  
  
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   P     \     h     t                              ,   Life Skills Strengths Needs Reporting Form                  Robbin DeFreitas                    cd97.dot          roetuwb       2         Microsoft Office Word   @    F#    @    l
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                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   /   0   1   2   3   4   5   6   7   8   9   :   ;   <   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   Q   R   S   T   U   V   W   X   Z   [   \   ]   ^   _   `   a   b   c   d   e   f   g   h   i   j   k   l   m   n   o   p   q   r   s   t   u   v   w   x   y   z   {   |   ~                                                                                                                                                                                                               R o o t   E n t r y                                                 	           F            [l          D a t a                                                         
                                     Y   ;G      1 T a b l e                                                                                                }   Kl      W o r d D o c u m e n t                                                                                        *       S u m m a r y I n f o r m a t i o n                           (                                                D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                                   C o m p O b j                                                                                           q                                                                                                                               
  	           F   Microsoft Office Word Document 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                                                                                                                                                                                                                           