CalWORKs Needs Assessment Form
Services Needed
I would like to further develop my skills in the following areas: (check all that apply)
Study Skills
Goal Setting
Time Management
Job Seeking Skills
Money Management
Self Esteem
Relationships
Parenting
Family Planning
Other
What type of transportation do you use?
Public transportation/Bus
Personal vehicle
Family/Friend vehicle
Other:
Do you have access to a computer?
Yes
No
In what academic areas do you experience difficulty? (check all that apply)
Reading
Reading Rate
Writing
Spelling
Math
Following Lecture
Taking Notes
Comprehending Concepts
Retaining Information
Organizing Ideas
Describe any other academic difficulties:
Study Skills
Meeting Deadlines
Taking Tests
Motivation
Self-Confidence
I expect the following may be barriers/obstacles to my success: (check all that apply)
Health Issues
Drug Abuse
Lack of Support
Finances
Legal Issues
Abusive Partner
Family Planning
Frequent Anger
Housing
Childcare
Few Interests
Other
Have you ever had difficulties with any of the following: (check all that apply)
Attention
Concentration
Hyperactivity
Describe difficulties during each of the following activities:
Study time:
Lecture:
Tests:
I require services on the basis of a disability:
Yes
No
If there are any other concerns, challenges or obstacles you face, please explain here:
Background
Do you have a misdemeanor or felony on your record?
Yes
No
If yes, please explain:
Are you currently on parole?
Yes
No
If yes, what are the conditions of your parole?
Vocational/Career Training and Development
What areas do you need assistance with? (check all that apply)
Job Search
Job Placement
Job Skills
Resume Writing
Would you be interested in career classes and/or workshops?
Yes
No
Have you requested Work Study?
Yes
No
Career Goals
What are your career goals?
How do you plan on reaching these goals?
What previous jobs have you held?
Do you need career counseling?
Yes
No
Interview Skills
Interview Attire
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