Customer In-Depth Assessment  New client

(Completed by staff and updated as needed)

 Returning client

Customer Name: _____________________________ Date:________ Staff Initials:_______

Confidentiality Statement: All information contained in this form will be considered confidential information.
Release of any of this information will require a signed consent to release by customer and [insert WorkOne Name]
staff person. If a referral is made on behalf of the customer in signing the referral form, the customer is consenting
to the information contained in this form to be released to the receiving agency.

Home and Family Situation

List all family members in household:
Name Relationship to Age Current School/Employment Situation
You

Are there any children currently not Yes No If yes, please explain
living with you?

Do you have child care Yes No What type?

services?

Referral Needed? Yes No Referral Agency: Date of Referral:

Are you a non-custodial parent? Yes No If yes, do you have visitation rights? Yes No

If you have visitation rights, about how often do you see Weekly Monthly A few times Never Other:
your children? a year
Are you paying child support? Yes No If no, how far behind in payments are you?

Do you need legal advice related to child support or visitation rights? Yes No

Referral Needed? Yes No Referral Agency: Date of Referral:

Is child support ordered for any Yes No If no, will you go to court to get support?
minor children in the home?

If yes, are you receiving the Yes No If no, how far behind in payments are you?
ordered child support?

[Insert Operator Name] is an Equal Employment Opportunity Employer/Program Provider 1

Is your family supportive of your efforts to Yes No Please explain
secure employment?

Who in your family will be most Who in your family will

supportive? be least supportive?
Have you or anyone in the household been a Yes No Please explain
victim of domestic violence?

Will your friends be supportive of your efforts Yes No Please explain

to secure employment?

Referral Needed? Yes No Referral Agency: Date of Referral:

Housing Situation
Current housing situation:
Referral Needed?
Own Rent Living with Friends Living at a hotel/motel
Living with Relatives: ____________ Homeless
 Not currently homeless, but was homeless within past two years
Yes No Referral Agency: Date of Referral:

Language
Preferred Language(s) spoken: English skills:  Speak  Read  Write  Comprehend
 Somewhat limited comprehension  Very limited comprehension
Referral Needed? Yes No Referral Agency: Date of Referral:

Legal Situation
Current Criminal Justice  No criminal record  On Bail/ROR  On probation
situation:  Conditional discharge Will be incarcerated on (date):_________
Alternatives to Incarceration  Conditional correctional supervision  On
parole Ex-offender – misdemeanor or felony (choose one)
Do you have a pending court date? Yes No If yes, when and for what?

Have you ever had any misdemeanors or Yes No If yes, what occurred and when? What was the type of
felony convictions? sentence?

Referral Needed? Yes No Referral Agency: Date of Referral:

Transportation
Do you own an operating vehicle? Yes No Do you have access to a vehicle on a daily basis? Yes No

If no to either question above, please explain:

Do you plan to have transportation within the Yes No If no, please explain:
next six months?

Referral Needed? Yes No Referral Agency: Date of referral:

Physical and Mental Health

How would you rate your overall health?  Poor  Fair  Good  Excellent

[Insert Operator Name] is an Equal Employment Opportunity Employer/Program Provider 2

Please describe any chronic illnesses you have:

Please identify any medications you are taking which would limit your ability to work?

Do you have health insurance? Yes No Does your family have health insurance? Yes No

Have you ever been treated or referred for Yes No If yes, please describe
emotional problems?

Do you feel you are currently suffering Yes No If yes, please describe
from emotional problems?

Have you had periods of depression or Yes No If yes, please describe

suicidal thoughts?

Referral Needed? Yes No Referral Agency: Date of Referral:

Substance Abuse
Have you ever resided in an inpatient drug Yes No If yes, please describe
and alcohol treatment program or an
outpatient program

Could you pass a drug screening if an Yes No If no, please describe

employer requested one?

Referral Needed? Yes No Referral Agency: Date of Referral:

Vocational Training
Vocational or job related training you have received Other special trade licenses, certificates or union
during employment or while in the military: affiliation:

Are you interested in receiving any additional vocational If yes, please describe:
or job-related training? Yes No

Are you interested in Yes No Have you completed the required career Yes No
accessing an ITA voucher? research paper?
Referral Needed? Yes No Referral Agency: Date of Referral:
(e.g. Major Opportunities, SSI, etc)

What would keep you from seeking or completing vocational or job-related training? Check all that apply.
 Lack of money  Undecided career goals
 Don’t know how to go about it  Lack of motivation

[Insert Operator Name] is an Equal Employment Opportunity Employer/Program Provider 3

 No transportation  Defaulted student loan(s)
 Lack of self-confidence  Other________________________________
 Family members/friends not supportive  Other________________________________

OPTIONAL INFORMATION
Goals
Where do you see yourself a year from now? Where do you see yourself five years from now?

What would you like to change about your life now? What is your employment goal?

Interests
What do you do for fun? How do you spend your free time?

Have you been involved in any volunteering, church or community activities?

Strengths/Assets
What do you feel are your greatest strengths? What do you feel are your greatest weaknesses?

Household Strengths and Assets/Other Assets

Who is the most supportive person in your life? What are some of the strengths and skills of the
members of your family?

Does your family participate in any church or community Are there any people you avoid (i.e., ex-spouse,
activities? estranged family member, etc.)?

Are there any other people in your life that you rely on for help, guidance, or support (i.e., partner pastor, teacher,
friend, etc.)?

Career/Occupational Interests
What type(s) of jobs are you What are the most important things Are you seeking:
interested in obtaining? you look for in a job? __ full-time __ part-time

Will you accept temporary

assignments?
 Yes  No
What is the ideal wage you are What is the lowest wage you would How far are you willing to travel one
[Insert Operator Name] is an Equal Employment Opportunity Employer/Program Provider 4
looking for? accept at a new job? way to accept work?

$___________ $___________ _________ miles

What shifts could you work? What types of work are you not able to perform due to medical reasons?
 First  Second  Third
 Split  Rotating
Do you think that you have enough education, training, skills and work experience to get the job you want?
 Yes  No Please explain.

Observed Behaviors (to be completed after the customer leaves)

Use the rating scale below to identify how the individual was/has been during office visits and discussions.
Rating
Area Comments
Poor Good
General appearance 1 2 3 4
General behavior 1 2 3 4
Mood 1 2 3 4
Flow of thought 1 2 3 4
Eye contact 1 2 3 4
Tries to argue about something you have 1 2 3 4
said
Overall attention to interview 1 2 3 4
What they were wearing 1 2 3 4
Hygiene 1 2 3 4
Brags about qualities others might try to 1 2 3 4
conceal
Gave complete answers 1 2 3 4
Other comments

Referral Needed? Yes No Referral Agency: Date of Referral:

Revised 2/11/2008

[Insert Operator Name] is an Equal Employment Opportunity Employer/Program Provider 5