CalWORKs Needs Assessment Form
Services Needed
I would like to further develop my skills in the following areas: (check all that apply)
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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?
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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)
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Reading
Reading Rate
Writing
Spelling
Math
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Following Lecture
Taking Notes
Comprehending Concepts
Retaining Information
Organizing Ideas
Describe any other academic difficulties:
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Study Skills
Meeting Deadlines
Taking Tests
Motivation
Self-Confidence
I expect the following may be barriers/obstacles to my success: (check all that apply)
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Health Issues
Drug Abuse
Lack of Support
Finances
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Legal Issues
Abusive Partner
Family Planning
Frequent Anger
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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