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) alarm clock calendar ability to get up on time resume	Needs the following: (Please Check) alarm clock calendar ability to get up on time resume
birth certificate social security card working papers non-driver's license	birth certificate social security card working papers 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: meeting new people speaking up for myself at home speaking up for myself at shool/work speaking up for myself with friends	Would like to be more comfortable with: meeting new people speaking up for myself at home speaking up for myself at shool/work 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: purchased a money order? written a check? opened a bank account? saved money for something big? filed income taxes? paid your own bills? made out a budget?	Learn more about how to: purchase a money order? writte a check? open a bank account? save money for something big? file income taxes? pay my own bills? 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: called for an appointment? used a thermometer? taken a first aid course? taken a CPR course? learned about BC and STD's? used birth control? gotten your medical history?	Would like to learn more about: calling for an appointment? using a thermometer? taking a first aid course? taking a CPR course? learning about BC and STD's? using birth control? 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: taken driver's education? obtained a driver's license?	Interested in: taking driver's education? getting a driver's license?
Other