| PRA | |||||||||
| OMB Control Number: 3170-00xx | |||||||||
| # | Category | Purpose | Indicator | Value Type | Values | Justification | Financial Coaching Core/Common Questions or Source | Modified (Y/N) | |
| 1 | Consumer Background | Consumer Biographical | First Name | Open Text | Write-in name | Allow the coach/counselor to establish a relationship with the consumer receiving financial coaching. | Social Solutions Internal | ||
| 2 | Consumer Background | Consumer Biographical | Middle Initial | Open Text | Write-in name | Allow the coach/counselor to establish a relationship with the consumer receiving financial coaching. | Social Solutions Internal | ||
| 3 | Consumer Background | Consumer Biographical | Last Name | Open Text | Write-in name | Allow the coach/counselor to establish a relationship with the consumer receiving financial coaching. | Social Solutions Internal | ||
| 4 | Consumer Background | Consumer Biographical | Street Address | Open Text | Write-in address | Allow the coach/counselor to establish a relationship with the consumer receiving financial coaching. | Social Solutions Internal | ||
| 5 | Consumer Background | Consumer Biographical | Zip | Open Text | Write-in address | Allow the coach/counselor to establish a relationship with the consumer receiving financial coaching. | Social Solutions Internal | ||
| 6 | Consumer Background | Consumer Biographical | Valid email | Write-in email | Allow the coach/counselor to establish a relationship with the consumer receiving financial coaching. | Social Solutions Internal | |||
| 7 | Consumer Background | Consumer Biographical | Primary Phone | Phone Number | Number value (###) ###-#### | Allow the coach/counselor to establish a relationship with the consumer receiving financial coaching. | Social Solutions Internal | ||
| 8 | Consumer Background | Consumer Biographical | DOB | Valid Date | Date value MM-DD-YYYY | Coaching: Allow the coach/counselor to ascertain how many years remain in the consumer's working life to shed light on potential future income streams; Program Analysis: Allow analysis of program impacts on different age groups. | Social Solutions Internal | ||
| 9 | Consumer Background | Consumer Biographical | Gender (expression of identity) | Dropdown | Male, Female | Allow analysis of program impacts on different demographic groups. | Social Solutions Internal | ||
| 10 | Consumer Background | Consumer Biographical | Ethnicity: | Dropdown | Hispanic or Latino Not Hispanic or Latino |
Allow analysis of program impacts on different demographic groups. | Social Solutions Internal | ||
| 11 | Consumer Background | Consumer Biographical | Race | Dropdown | American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other |
Allow analysis of program impacts on different demographic groups. | Social Solutions Internal | ||
| 12 | Consumer Background | Consumer Biographical | Nativity | Dropdown | US Born Foreign born Naturalized US citizen Foreign born non-citizen |
Allow determination of programs based on citizenship status and analysis of program impacts on different demographic groups | Social Solutions Internal | ||
| 13 | Consumer Background | Consumer Biographical | Marital Status | Dropdown | Single, Married, Widowed, Separated, Divorced, Domestic Partner, Common Law | Coaching: Provide coach/counselor with information required to establish a family budget and/or to understand the consumer's complete financial situation. Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions Internal | ||
| 14 | Consumer Background | Consumer Biographical | Language Preference | Dropdown | English, Spanish, Chinese, American Sign Language, Other write in | Coaching: Allow the coach/counselor to determine what language the client prefers to get services | Social Solutions Internal | Yes, added American Sign Language. | |
| 15 | Consumer Background | Consumer Biographical | Other Language | Open Text | Other (write in) | Coaching: Allow the coach/counselor to determine what language the client prefers to get services | Social Solutions Internal | ||
| 16 | Consumer Background | Consumer Biographical | Highest level of Education completed | Dropdown | No High School, Some High School, Completed High School, Some College, Associate's Degree, Bachelor's Degree, More Than College | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased employment income; analysis: allow analysis of program impacts on different demographic groups. | Social Solutions Internal | ||
| 17 | Consumer Background | Consumer Biographical | Do you or a family member living in your household have a disability? | Multi-select | Self, Spouse, Dependent, Other, No disability present | Allow analysis of program impacts on different demographic groups. | National Disabiltiy Institute | IRS adopted this question for the Volunteer Income Tax Asssistance (VITA) national work 2008. Allows field to understand the needs and filing issues for taxpayers with disabilities when compared to data on taxpayers without disabilities. | |
| 18 | Consumer Background | Consumer Biographical | Type of Disability | Dropdown | Permanent Mobility and Physical Impairments, including spinal Cord Disability; Head injuries- Disabilities such as Acquired Brain injury or Traumatic Brain Injury, Vision, Hearing, Cognitive or Learning Disabilities, Mental Health, Intellectual or Developmental Disability, Other | Allow analysis of program impacts on different demographic groups. | National Disability Institute | Yes. Added more specificity to broad categories of physical, mental hearing and vision. | |
| 19 | Consumer Background | Consumer Biographical | Are you or a family member affiliated with the US Armed Forces? (Self, member of the immediate family) | Dropdown | Yes, No, Self, Member of Immediate Family | Allow analysis of program impacts on different demographic groups. | September 2010. | ||
| 20 | Consumer Background | Consumer Biographical | If Yes, what best describes you? | Dropdown | Retiree Veteran Reserves Active-duty |
Allow analysis of program impacts on different demographic groups. | Social Solutions Internal | ||
| 21 | Consumer Background | Consumer Biographical | If Yes, what branch? | Dropdown | Air Force Army Navy Marine Corps Coast Guard |
Allow analysis of program impacts on different demographic groups. | Social Solutions Internal | ||
| 22 | Consumer Background | Consumer Biographical | Are you a student taking courses for credit? | Dropdown | Part-time Full-time Four-year college or university Two-year community colleges Vocational, technical, or trade school Other |
Allow analysis of program impacts on different demographic groups. | Social Solutions Internal | ||
| 23 | Consumer Background | Consumer Biographical | How did you hear about this program? | Open Text | Fillable text box | Allow analysis of impacts of communications techniques | Sandard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, | To document referal source, expand partnerships |
| 25 | Consumer Background | Consumer Biographical | If Yes, Is there a specific accommodation that you need to participate in the counseling/coaching services offered? One-on-one or group class? | Dropdown | American Sign Language Interpreter Assistive Technology Devices Large Print Braille Microphone Screen Reader Others? |
Coaching: Provide coach/counselor with information required to understand the consumer's need for accommodation; Analysis: allow analysis of program impacts on different demographic groups. | National Disability Institute | ||
| 33 | Consumer Background | Consumer Biographical | Household composition | Fillable form captures amounts of each category | Number of Adults 18 or over in Household Number of Children under 18 in Household Number of Children in Household at least 50% financially dependent on you |
Coaching: Provide coach/counselor with information required to establish a family budget and/or to understand the consumer's complete financial situation. Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 34 | Consumer Background | Consumer Biographical | Employment status | Dropdown | No job, not actively searching No job; cannot work - temporary (e.g. new baby, full-time education), No job; cannot work – permanent (e.g. permanent disability, retired) No job and capable of working with my disability, but putting little effort into search No job and capable of working with my disability but afraid to work because I could lose my benefits No job but actively searching Employed, dissatisfied Employed, satisfied |
Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased employment income; analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 35 | Consumer Background | Consumer Biographical | Are you currently receiving support in your employment search? Yes/No | Dropdown | Yes, No | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased employment income; analysis: allow analysis of program impacts on different demographic groups. | Sandard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, | |
| 36 | Consumer Background | Consumer Biographical | If answered yes, then from which agency/organization? | Open Text | Write in | Detail provided on services for program enhancement | Sandard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, | |
| 37 | Consumer Background | Consumer Biographical | Employer type details | Open Text | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased employment income; analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | |||
| 38 | Consumer Background | Consumer Biographical | Hourly pay | Numerical form | ($) | Coaching: Provide coach/counselor with information required to understand the consumer's current income; Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 39 | Consumer Background | Consumer Biographical | Number of hours worked per week, on average | Numerical form | (Hours) | Coaching: Provide coach/counselor with information required to establish a family budget and/or to understand the consumer's complete financial situation. Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 40 | Consumer Background | Consumer Biographical | Paid leave | Dropdown | Yes, No | Allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 41 | Consumer Background | Consumer Biographical | Current employee benefits | Dropdown | Health insurance, 401K, Life Insurance, Other | Allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 42 | Consumer Background | Consumer Biographical | Employed Since | Valid Date | (Date) | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 43 | Consumer Background | Consumer Biographical | If No Job, Unemployed since (date) | Valid Date | (Date) | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 44 | Consumer Background | Consumer Biographical | Are you aware of Social Security Administration Work Incentive counseling services with return to work focus | Dropdown | Yes, No, Want to know more | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 45 | Consumer Background | Consumer Biographical | What, if any, educational path is participant pursuing? | Dropdown | None, HS/GED, College, Vocational certificate | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 46 | Consumer Background | Consumer Biographical | If HS/GED, what progress? | Dropdown | Not enrolled, Enrolled and in danger of dropping out, Enrolled and on track to completing, Obtained HS diploma/GED | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 47 | Consumer Background | Consumer Biographical | If College, what progress? | Dropdown | Not enrolled Enrolled and in danger of dropping out Enrolled and on track to completing Obtained 2-year college diploma Obtained 4-year college diploma |
Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 48 | Consumer Background | Consumer Biographical | If Vocational certificate, what progress? | Dropdown | Not enrolled Enrolled and in danger of dropping out Enrolled and on track to completing Obtained vocational certificate |
Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; Analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | ||
| 931 | |||||||||
| 596 | |||||||||
| 36% |
| PRA | ||||||||
| OMB Control Number: 3170-00xx | ||||||||
| # | Category | Purpose | Indicator | Value Type | Values | Justification | Financial Coaching Core/Common Questions or Source | Modified (Y/N) |
| 24 | Coaching History | Consumer Discovery | Would you like to meet with a financial coach? | Dropdown | Yes, No | Coaching: Provide coach/counselor with information required to understand the customers motivations. | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 26 | Coaching History | Consumer Discovery | If No, Are you an active Vocational Rehabilitation Client? | Dropdown | Yes, No | Coaching: Provide coach/couselor with information required to understand the customer's potential for increased employment income; allow analysis of program impacts on different demographics specific to customers with disabilities. | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 27 | Coaching History | Consumer Discovery | If No, Are you registered for services with the Workforce Investment System? | Dropdown | Yes, No | Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased employment income; analysis: allow analysis of program impacts on different demographic groups. | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 28 | Benefits Usage | Consumer Discovery | Do you receive WIC | Dropdown | Eligibility unknown Not eligible Eligible, but have not applied Application in process Receiving benefit |
Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | |
| 29 | Benefits Usage | Consumer Discovery | Do you receive SNAP (food stamps)? | Dropdown | Eligibility unknown Not eligible Eligible, but have not applied Application in process Receiving benefit |
Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | |
| 30 | Benefits Usage | Consumer Discovery | Do you receive TANF? | Dropdown | Eligibility unknown Not eligible Eligible, but have not applied Application in process Receiving benefit |
Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | |
| 31 | Benefits Usage | Consumer Discovery | Total monthly non-cash benefits | Multi-select | Family Medicaid and Individual Medicaid Food Stamps Section 8 vouchers Energy Assistance Rental Assistance State Child Health Insurance Program Special Needs Trust Pooled Trust State waivers Social Security Pension Other |
Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | Yes, added several disability specific non-cash benefit categories previsouly not collected to better understand interaction of benefits with asset limits and ability to save toward goal. |
| 32 | Benefits Usage | Consumer Discovery | Total monthly cash benefits/income amount | Fillable form captures amounts of each benefit amount | Child support Earned income General assistance Social Security Disability Income (SSDI) Supplemental Security Income (SSI) Temporary Assistance for Needy Families (TANF) Unemployment insurance Other |
Coaching: Provide coach/counselor with information required to understand the consumer's potential for increased income; analysis: allow analysis of program impacts on different demographic groups. | Social Solutions | Yes, added several disability specific cash benefit categories previsouly not collected to better understand interaction of income/ benefits and asset limits and ability to save toward goal. |
| 49 | Assets | Consumer Discovery | Do you own any or all of the following assets? | Dropdown | Home Car Other |
Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Standard Coaching Intake Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 50 | Debts | Consumer Discovery | If Credit Cards Debt selected, How many credit cards do you have? | Numerical form | Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Standard Coaching Intake Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, | |
| 51 | Debts | Consumer Discovery | Please list the following types of debt you currently have: | Fillable form captures amounts of each category | Student loan debt, Credit card/consumer loan, Assistive Technology or Durable Medical Equipment Loan, Mortgage, Credit Cards, Home Mortgage/Rent, Car Payment, Insurance, Child Support, Rent-to-Own, Other (write in) | Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Social Solutions | Yes, added disability specific debt types |
| 52 | Debts | Consumer Discovery | What describes your current state of thinking regarding paying off your debt? | Dropdown | Not thinking about paying-off debts, Thinking about paying-off debts, Actively making a plan to pay-off debts, Pays-off consumer debt monthly, makes regular payments on larger debt like mortgage and student loans |
Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Social Solutions | |
| 53 | Credit | Consumer Discovery | How would you describe your use of credit? | Dropdown | Don’t have any credit cards or loans outstanding, Have one or more credit card accounts, but pay them off in full every month, Make the minimum payment on my credit cards, Maxed out on my credit card accounts so use them sparingly to make purchases | Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Social Solutions | |
| 54 | Credit | Consumer Discovery | Consumer report (credit report) status | Dropdown | Unknown never pulled Unknown, not recently pulled Incorrect information on credit report – no action taken Incorrect information on credit report– actions taken to correct it Correct |
Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Social Solutions | |
| 55 | Credit | Consumer Discovery | If answered “Unknown”, why has the participant never pulled his/her credit report? | Dropdown | Wasn’t interested Couldn’t Don’t know how Didn’t understand previously pulled report Didn’t know benefits of obtaining a report in the past |
Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Social Solutions | |
| 56 | Credit | Consumer Discovery | If answered “incorrect” or “correct”, how often does the participant review his/her credit record? | Dropdown | Infrequently – once or twice total Frequently – every few years Regularly – every 12 months or more |
Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Social Solutions | |
| 57 | Credit | Consumer Discovery | What do you believe is your current credit score? | Dropdown | Very high (750-850) High (700-749) Middle (660-699) Somewhat Low (620-659) Very Low (340-619) Don’t Know/Don’t have a Credit Score |
Coaching: Identify the progress already made by the consumer before formal coaching begins; Analysis: allow the program to analyze the uses to which consumers are putting the coaching services. | Social Solutions | |
| 58 | Credit | Consumer Discovery | How sure are you of this score? | Dropdown | Very Sure Sure Unsure Very Unsure Don’t Know/Don’t have a Credit Score |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Social Solutions | |
| 59 | Credit | Consumer Discovery | Most recent credit report, score and date | Numerical form | Enter Score | Coaching: Allow the coach/counselor to determine credit score and review credit file for determination of services | Social Solutions | |
| 60 | Debts | Consumer Discovery | Did you file your income taxes? (Yes, No) | Dropdown | Yes, No (for each year covered by the project 2010-2019) | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer and to assist customers in gaining access to free, quality, trusted servcies. | National Disability Institute, IRS, AARP, Volunteer Income Tax Assistance Coalitions, and most coaching programs include this question | |
| 61 | Debts | Consumer Discovery | Do you have access to free tax assistance? | Dropdown | Yes, No, I don't know | Provide the coach/counselor with an understanding of the consumer's existing financial resources. | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 62 | Debts | Consumer Discovery | Have you ever claimed the Earned Income Tax credit? | Dropdown | Yes, No, I don't know | Provide the coach/counselor with an understanding of the consumer's existing financial resources. | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 63 | Debts | Consumer Discovery | If you filed a tax return in the past or this year did you use | Dropdown | Free In Person Service Filed Taxes Online for Free Friend or Family prepared them for me Paid to file Taxes online Paid preparer Self-prepared via paper forms |
Provide the coach/counselor with an understanding of the consumer's existing financial resources. | Standard Intake Coaching Question | IRS conducts a yearly national survey that collects this information. It has become common practice for financial coaching programs to do the same. |
| 64 | Consumer Protection | Consumer Discovery | Have you ever experienced financial fraud or abuse - financial exploitation, the illegal or improper use of your money? | Dropdown | Yes, No | Provide the coach/counselor with necessary information to ascertain the fraud and abuse awareness already possessed by the consumer | NEW | Synthesized CFPB Question for client specific programming |
| 65 | Consumer Protection | Consumer Discovery | If yes, do you know where to go to report the abuse? | Dropdown | Yes, No | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer | NEW | Synthesized CFPB Question for client specific programming |
| 66 | Consumer Protection | Consumer Discovery | Are you currently experiencing a problem with a consumer financial product or service? | Dropdown | Yes, No | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer | NEW | Synthesized CFPB Question for client specific programming |
| 67 | Consumer Protection | Consumer Discovery | Are you currently being contacted by a debt collector? | Dropdown | Yes, No | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer | NEW | Synthesized CFPB Question for client specific programming |
| 68 | Consumer Protection | Consumer Discovery | Would you like to learn how to submit a complaint to the Consumer Financial Protection Bureau? | Dropdown | Yes, No | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer | NEW | Synthesized CFPB Question for client specific programming |
| 69 | Consumer Protection | Consumer Discovery | Do you know the steps you should take to protect your identify? | Dropdown | Yes, No | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer | NEW | Synthesized CFPB Question for client specific programming |
| 70 | Consumer Background | Consumer Discovery | Which is the best description of your housing situation? | Dropdown | Homeless – the individual/family has no place to live, is squatting or living out of doors Living in temporary/transitional housing – the individual/family has no permanent place to live, is living in a shelter or transitional residential program Living in permanent but sub-standard housing – the individual/family is living in owned or a rented space, may not be able to afford what it costs to maintain this situation, and conditions are overcrowded, unsafe, or otherwise unsatisfactory and may not be fully accessible for tenant with mobility issue etc. Living in permanent, appropriate housing – the individual/family is living it its own or a rented space, can afford to maintain this situation, and conditions are safe and satisfactory Living in Group Housing – the individual is living on its own in rented space with XXX other people with disabilities. |
Provide the coach/counselor with an understanding of the consumer's existing financial resources. | Social Solutions | |
| 71 | Consumer Background | Consumer Discovery | If group house, how many other persons with disabilities are living in the same house? | Numerical form | People with disabilities may live in homes with other people with disabilities. Each person in the home would have its own source of income. Often, means tested programs rely on the entire household income when calculating benefit eligibility. A Group Home (or house) is a different entity in this regard. Multiple incomes in this case do not reflect "household income." | NEW NDI | ||
| 72 | Financial Background | Consumer Discovery | Which of the following best describes your household’s finances? | Dropdown | The adults have shared finances The adults have some shared finances and some separate finances The adults have separate finances even though we share living space I am the only adult in the household DK/Refused |
Provide the coach/counselor with an understanding of the customer's existing financial resources. | FDIC | https://www.fdic.gov/regulations/laws/federal/2013/2013-03-19_notice_03_household-survey.pdf |
| 73 | Financial Background | Consumer Discovery | How much do you participate in making financial decisions for your household? | Dropdown | A lot Some Not at all DK/Refused |
Provide the coach/counselor with an understanding of the consumer's existing financial resources. | FDIC | |
| 74 | Banking Usage | Consumer Discovery | Do you or does anyone in your household currently have a checking or savings account? | Dropdown | Yes No DK/Refused |
Provide the coach/counselor with an understanding of the consumer's existing financial resources. | FDIC | |
| 75 | Banking Usage | Consumer Discovery | What type or types of accounts do you or family members currently have? | Dropdown | Only checking account Only savings account Both checking and savings accounts Other DK/Refused |
Provide the coach/counselor with an understanding of the consumer's existing financial resources. | FDIC | |
| 76 | Banking Usage | Consumer Discovery | In the past 12 months have you or anyone in your household used any of the following methods to access an account? | Dropdown | Bank teller ATM/Kiosk Telephone banking through phone call or automated voice/touch tone Online banking through desktop, laptop, or tablet computer (e.g, IPad) Mobile Banking through text messaging, mobile apps, or Internet browser or email on phone Other Did not access an account in the past 12 months Don’t Know/Refused |
Provide the coach/counselor with an understanding of the consumer's existing financial resources. | FDIC | |
| 77 | Banking Usage | Consumer Discovery | Are you or member of your household enrolled in Individual Development Account or other savings program? | Dropdown | Yes, No | Provide the coach/counselor with an understanding of the consumer's existing financial resources. | FDIC | Coalitions that offer Indivdual Development Accounts often ask this question along with the general savings question. |
| 78 | Financial Background | Consumer Discovery | Amount of monthly living expenses | Fillable form captures amounts of each category | Electric, Gas, Water and Waste, Cell Phone/Telephone, Internet, Cable/Satellite. Contribution to Savings, Other (please specify) | Provide the coach/counselor with an understanding of the consumer's existing financial resources. | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 79 | Financial Background | Consumer Discovery | Amount of total emergency savings | Numerical form | ($) | Provide the coach/counselor with an understanding of the consumer's existing financial resources. | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 80 | Fringe Services | Consumer Discovery | Have you used these alternative loan/alternative financial services at least once? (Past Month, Past six months, Past year, More than a year, Never) | Dropdown | Check Cashing, Money order, Remittance, Payday Loan, Rent-to-own, Pawn Shop, Refund Anticipation Loan | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FDIC | |
| 81 | Financial Background | Consumer Discovery | Over the last 3 months, have you followed a personal budget, spending plan, or financial plan? | Dropdown | Yes, No, I don't know | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FDIC | |
| 82 | Coaching History | Consumer Discovery | Do you currently have a least one financial goal? | Dropdown | Yes, No | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FDIC | |
| 83 | Coaching History | Consumer Discovery | If Yes, which of these apply? | Dropdown | Create a plan to use a budget Reduce existing expenses Increase savings Increase income Improve credit score Establish/build credit Pay bills Reduce Debt Access Assistive Technology Loan Fund Access financial products/services Access mortgage lending services Access small business lending resources |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Standard Intake Coaching Question | Yes. NDI included Access Assistive Technology Loan Fund. For people with disabilities this is a common loan category not reflected on national financial capabiltiy surveys. |
| 84 | Coaching History | Consumer Discovery | How confident are you in your ability to achieve a financial goal you set for yourself today? | Dropdown | Not confident, Confident | Provide the coach/counselor with an understanding of the consumer's existing ability to meet goals. | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 85 | Financial Background | Consumer Discovery | In the last 3 months, did you use an automatic deposit or transfer to put money away for a future use such as saving for retirement or education? | Dropdown | Yes, No, I don't know | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | YES Added timeframe and examples for savings. |
| 86 | Financial Background | Consumer Discovery | In the last 3 months, did you manually deposit cash, check or other to put money away for a future use such as saving for retirement or education? | Dropdown | Yes, No, I don't know | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | YES Added examples for savings. |
| 87 | Financial Background | Consumer Discovery | Have you set aside emergency or rainy day funds that would cover your expenses for 3 months, in case of sickness, job loss, economic downturn or other emergencies? | Dropdown | Yes, No, I don't know | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | YES Added examples. |
| 88 | Financial Background | Consumer Discovery | Over the past 3 months, would you say your household’s spending was less than, more than or about equal to your income? Please do not include large, one-time purchases such as a house or car. | Dropdown | Less than More than Equal to Don’t know |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 89 | Financial Background | Consumer Discovery | In the last 3 months, have you paid a late fee on a loan or bill? | Dropdown | Yes, No, I don't know | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 90 | Financial Attitudes | Consumer Discovery | Considering your financial, savings, and expenses situation, when you think about big ticket items such as furniture, a refrigerator, an automobile, a television and things like that, do you think it would be: | Dropdown | An excellent time to buy A good time to buy Only a fair time A poor time to buy |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | CFSI | |
| 91 | Financial Attitudes | Consumer Discovery | Would you say your own personal finance situation is better now, worse now or about the same as it was a year ago? | Dropdown | Better than a year ago Same as a year ago Worse than a year ago |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | CFSI | |
| 92 | Financial Background | Consumer Discovery | Here are some ways people manage the way they spend and save. Which of these steps have you taken in the last year? | Dropdown | Cut down on credit card purchases Paid down debt/reduced the amount of money you owe Taken on another credit card Taken out additional loans/borrowed money Postponed the purchase of a major item like an automobile or furniture Taken money out of savings to cover living expenses Sold car or house or other big item Changed living arrangements in order to save money Worked longer hours or taken a second job to earn more money Postponed retirement Put more purchases on your credit card so you didn’t have to pay for things immediately Made minimum payments on credit cards rather than paying them off immediately Cut down on non-essential spending like restaurants or vacations Shopped more at discount stores and warehouse clubs Use layaway to make big purchases |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Social Solutions | |
| 93 | Financial Attitudes | Consumer Discovery | Do you feel better, worse or the same about your financial status compared to six months ago? | Dropdown | Better, Worse, Same | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 94 | Financial Attitudes | Consumer Discovery | How would you describe your savings now when compared to six months ago, better, worse or the same? | Dropdown | Better, Worse, Same | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 95 | Financial Attitudes | Consumer Discovery | How would you describe your debt now when compared to six months ago, better, worse or the same? | Dropdown | Better, Worse, Same | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 96 | Financial Background | Consumer Discovery | In a typical month, how difficult is it for you to cover your expenses and pay all your bills? | Dropdown | Not difficult, Somewhat difficult, Very difficultVery difficult Somewhat difficult Not at all difficult Don’t know Prefer not to say |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 97 | Financial Background | Consumer Discovery | Have you set aside any money for after high school education or other training for you or your children? | Dropdown | Yes No Don’t Know Prefer not to say |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 98 | Financial Background | Consumer Discovery | Have you ever tried to figure out how much you need to save for retirement? | Dropdown | Yes No Don’t Know Prefer not to say |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 99 | Financial Background | Consumer Discovery | Has your household experienced a large drop in income which you did not expect? | Dropdown | Yes No Don’t Know Prefer not to say |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 100 | Financial Background | Consumer Discovery | How confident are you that you could come up with $2000 if an unexpected need arose within the next month? | Dropdown | I am certain I would come up with the full $2000 I could probably come up with $2000 I could probably not come up with $2000 I am certain I could not come up with $2000 Don’t know Prefer not to say |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 101 | Financial Background | Consumer Discovery | In the last 5 years have you asked for any advice from a financial professional about any of the following? | Dropdown | Debt counseling Savings or investment Taking out a mortgage or a loan Insurance of any type Tax planning |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 102 | Coaching History | Consumer Discovery | Do you take care of your own financial business? | Dropdown | Yes, No | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | FINRA | |
| 103 | Coaching History | Consumer Discovery | Do you have a financial goal (s) that requires long-term savings or investment? | Dropdown | Yes No Don’t Know Refused Not applicable |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 104 | Coaching History | Consumer Discovery | What will you use your long-term savings/investment for? | Dropdown | Motor Vehicle Motor Vehicle Modification Home Home Improvement/Modification Small Business Development Investment Account Retirement Education Mobility Related Purchase (wheelchair, assistive technology, etc.) Other |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Standard Intake Coaching Question | |
| 105 | Coaching History | Consumer Discovery | What other uses might you use this long-term savings for? | Dropdown | To travel back and forth to work To improve access to employment opportunities To improve mobility and/or sensory or cognitive functioning (purchase of new wheelchair, Braille reader, VRS phone, prostheses, AT, etc. rehabilitation services/procedures not covered by insurance) To improve accessibility to apartment or home To build an employment opportunity for myself To prepare for my retirement To take a course to improve job skills |
Track long-term savings goal, level of awareness to evaluate program effectiveness, and understand usage for people with disabilities. | Standard Intake Coaching Question | Yes. NDI. Many people with disabilities are faced with expenses specific to their disability that require planning and savings. |
| 106 | Coaching History | Consumer Discovery | Have you created a plan to achieve your goal? | Dropdown | Yes No Don’t Know Refused Not applicable |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Standard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 107 | Coaching History | Consumer Discovery | What is your target date for achieving goal? | Dropdown | 0-3 Months 3-6 Months 6- 12 Months 1 -2 Years 3-5 Years 5-10 Years More than 10 Years |
Provide the coach/counselor with an understanding of the consumer's existing ability to set and achieve new goals | Sandard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 108 | Coaching History | Consumer Discovery | What areas can the coach or counselor assist you with to achieve this goal? | Dropdown | Create a plan to use a budget Reduce existing expenses Increase savings Improve credit score Establish/build credit Reduce Debt Access Assistive Technology Loan Fund Access financial products/services Access mortgage lending services Access small business lending resources |
Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Standard Intake Coaching Questions | Yes. NDI added in Access Assistive Technology Loan Fund. |
| 109 | Coaching History | Consumer Discovery | Did you achieve a goal? | Dropdown | Yes No In Progress |
Provide the coach/counselor with an understanding of the consumer's existing ability to set and achieve new goals | Sandard Intake Coaching Question | National Coaching Programs such as NeighborWorks, The Financial Clinic, NY, $tand By Me, DE, Cities for Financial Empowerment (CFE), University of Wisconsin, Center on Financial Coaching Services, CFED, National Disability Institute, |
| 110 | Self Sufficiency Matrix | Consumer Discovery | Housing (select from choices 1 - 5) | Dropdown | Homeless or threatened with eviction.Homeless or threatened with eviction. In transitional, temporary or substandard housing; and/or current rent/mortgage payment is unaffordable (over 30% of income). In stable housing that is safe but only marginally adequate. Household is in safe, adequate subsidized housing. Household is safe, adequate, unsubsidized housing. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | http://www.ctagroup.org/wp-content/uploads/SSM-Standards-2010-Oct.pdf |
| 111 | Self Sufficiency Matrix | Consumer Discovery | Employment (select from choices 1 - 5) | Dropdown | No job. Temporary, part-time or seasonal; inadequate pay, no benefits. Employed full time; inadequate pay; few or no benefits. Employed full time with adequate pay and benefits. Maintains permanent employment with adequate income and benefits. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 112 | Self Sufficiency Matrix | Consumer Discovery | Income (select from choices 1 - 5) | Dropdown | No income. Inadequate income and/or spontaneous or inappropriate spending. Can meet basic needs with subsidy; appropriate spending. Can meet basic needs and manage debt without assistance. Income is sufficient, well managed; has discretionary income and is able to save. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 113 | Self Sufficiency Matrix | Consumer Discovery | Food (select from choices 1 - 5) | Dropdown | No food or means to prepare it. Relies to a significant degree on other sources of free or low-cost food.No food or means to prepare it. Relies to a significant degree on other sources of free or low-cost food. Household is on food stamps. Can meet basic food needs, but requires occasional assistance. Can meet basic food needs without assistance. Can choose to purchase any food household desires. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 114 | Self Sufficiency Matrix | Consumer Discovery | Child Care (select from choices 1 - 5) | Dropdown | Needs childcare, but none is available/accessible and/or child is not eligible. Childcare is unreliable or unaffordable, inadequate supervision is a problem for childcare that is available. Affordable subsidized childcare is available, but limited. Reliable, affordable childcare is available, no need for subsidies. Able to select quality childcare of choice. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 115 | Self Sufficiency Matrix | Consumer Discovery | Children's Education (select from choices 1 - 5) | Dropdown | One or more school-aged children not enrolled in school.One or more school-aged children not enrolled in school. One or more school-aged children enrolled in school, but not attending classes. Enrolled in school, but one or more children only occasionally attending classes. Enrolled in school and attending classes most of the time. All school-aged children enrolled and attending on a regular basis. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 116 | Self Sufficiency Matrix | Consumer Discovery | Adult Education (select from choices 1 - 5) | Dropdown | Literacy problems and/or no high school diploma/GED are serious barriers to employment. Enrolled in literacy and/or GED program and/or has sufficient command of English to where language is not a barrier to employment. Has high school diploma/GED. Needs additional education/training to improve employment situation and/or to resolve literacy problemsto where they are able to function effectively in society. Has completed education/training needed to become employable. No literacy problems. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 117 | Self Sufficiency Matrix | Consumer Discovery | Health Care Coverage (select from choices 1 - 5) | Dropdown | No medical coverage with immediate need. No medical coverage and great difficulty accessing medical care when needed. Some household members may be in poor health. Some members (e.g. Children) have medical coverage. All members can get medical care when needed, but may strain budget. All members are covered by affordable, adequate health insurance. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 118 | Self Sufficiency Matrix | Consumer Discovery | Life Skills (select from choices 1 - 5) | Dropdown | Unable to meet basic needs such as hygiene, food, activities of daily living. Can meet a few but not all needs of daily living without assistance. Can meet most but not all daily living needs without assistance. Able to meet all basic needs of daily living without assistance. Able to provide beyond basic needs of daily living for self and family. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 119 | Self Sufficiency Matrix | Consumer Discovery | Family /Social Relations (select from choices 1 - 5) | Dropdown | Lack of necessary support form family or friends; abuse (DV, child) is present or there is child neglect. Family/friends may be supportive, but lack ability or resources to help; family members do not relate well with one another; potential for abuse or neglect. Some support from family/friends; family members acknowledge and seek to change negative behaviors; are learning to communicate and support. Strong support from family or friends. Household members support each other’s efforts. Has healthy/expanding support network; household is stable and communication is consistently open. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 120 | Self Sufficiency Matrix | Consumer Discovery | Mobility (select from choices 1 - 5) | Dropdown | No access to transportation, public or private; may have car that is inoperable. Transportation is available, but unreliable, unpredictable, unaffordable; may have car but no insurance, license, etc. Transportation is available and reliable, but limited and/or inconvenient; drivers are licensed and minimally insured. Transportation is generally accessible to meet basic travel needs. Transportation is readily available and affordable; car is adequately insured. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 121 | Self Sufficiency Matrix | Consumer Discovery | Community Involvement (select from choices 1 - 5) | Dropdown | Not applicable due to crisis situation; in “survival” mode. Socially isolated and/or no social skills and/or lacks motivation to become involved. Lacks knowledge of ways to become involved. Some community involvement (advisory group, support group), but has barriers such as transportation, childcare issues. Actively involved in community. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 122 | Self Sufficiency Matrix | Consumer Discovery | Legal (select from choices 1 - 5) | Dropdown | Current outstanding tickets or warrants. Current charges/trial pending, noncompliance with probation/parole. Fully compliant with probation/parole terms. Has successfully completed probation/parole within past 12 months, no new charges filed. No active criminal justice involvement in more that 12 months and/or no felony criminal history. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 123 | Self Sufficiency Matrix | Consumer Discovery | Mental Health (select from choices 1 - 5) | Dropdown | Danger to self or others; recurring suicidal ideation; experiencing severe difficulty in day-to-day life due to psychological problems. Recurrent mental health symptoms that may affect behavior, but not a danger to self/others; persistent problems with functioning due to mental health symptoms. Mild symptoms may be present but are transient; only moderate difficulty in functioning due to mental health problems. Minimal symptoms that are expectable responses to life stressors; only slight impairment in functioning. Symptoms are absent or rare; good or superior functioning in wide range of activities; no more than every day problems or concerns. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 124 | Self Sufficiency Matrix | Consumer Discovery | Substance Abuse (select from choices 1 - 5) | Dropdown | Meets criteria for severe abuse/dependence; resulting problems so severe that institutional living or hospitalization may be necessary. Meets criteria for dependence; preoccupation with use and/or obtaining drugs/alcohol; withdrawal or withdrawal avoidance behaviors evident; use results in avoidance or neglect of essential life activities. Use within last 6 months; evidence of persistent or recurrent social, occupational, emotional or physical problems related to use (such as disruptive behavior or housing problems); problems have persisted for at least one month. Client has used during last 6 months, but no evidence of persistent or recurrent social, occupational, emotional, or physical problems related to use; no evidence of recurrent dangerous use. No drug use/alcohol abuse in last 6 months. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 125 | Self Sufficiency Matrix | Consumer Discovery | Safety (select from choices 1 - 5) | Dropdown | Home or residence is not safe; immediate level of lethality is extremely high; possible CPS involvement. Safety is threatened/temporary protection is available; level of lethality is high. Current level of safety is minimally adequate; ongoing safety planning is essential. Environment is safe, however, future of such is uncertain; safety planning is important. Environment is apparently safe and stable. |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 126 | Self Sufficiency Matrix | Consumer Discovery | Disabilities (select from choices 1 - 5) | Dropdown | In crisis – acute or chronic disability affecting housing, employment, social interactions, etc. Vulnerable – sometimes or periodically has acute or chronic disability affecting housing, employment, social interactions, etc. Safe – rarely has acute or chronic disability affecting housing, employment, social interactions, etc. Building Capacity – disability controlled by services or medication Thriving |
For coaches and counselors, working with individual clients to document progress towards self-sufficiency over time at specific intervention points or, when appropriate, to document a client’s ability to maintain a certain level of functioning. For clients who want guidance in looking at their own strengths and areas for improvement as they work toward independence from public assistance. | Arizona Self-Sufficiency Matrix | |
| 127 | Coaching History | Consumer Discovery | What is the area of concern or targeted issue? | Dropdown | Housing, Employment, Credit, Income, Debt, Food, Childcare, Savings, Consumer Protection, Children’s Education, Adult Education, Health Care Coverage, Life Skills, Family Social Relationships, Mobility, Community Involvement, Parenting Skills, Legal, Mental Health, Substance Abuse | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Social Solutions | |
| 128 | Coaching History | Consumer Discovery | If Credit Selected: Most recent credit score | Open Text | Write in Valid Credit Score | Provide the coach/counselor with necessary information to ascertain the financial awareness already possessed by the consumer; Track changes in this level of awareness to evaluate program effectiveness | Social Solutions | |
| 129 | Coaching History | Consumer Discovery | Goals set during coaching session | Open Text | Free text field for client goal | Provide the coach/counselor with an understanding of the consumer's existing ability to meet goals | Social Solutions | |
| 130 | Coaching History | Consumer Discovery | Client Activities set during coaching session | Open Text | Free text field for activities to be completed by next followup appointment | Provide the coach/counselor with an understanding of the consumer's existing ability to meet goals | Social Solutions | |
| 131 | Coaching History | Consumer Discovery | Target Completion Date | Open Text | date value: MM-DD-YYYY | Provide the coach/counselor with an understanding of the consumer's existing ability to meet goals | Social Solutions | |
| 132 | Coaching History | Consumer Discovery | What goal achieved? | Open Text | Write in Achieved Goal | Provide the coach/counselor with an understanding of the consumer's existing ability to meet goals | Social Solutions | |
| 133 | Coaching History | Consumer Discovery | What percentage is complete? | Open Text | (Enter a percentage (20%, 30%, etc) | Provide the coach/counselor with an understanding of the consumer's existing ability to meet goals | Social Solutions |
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| File Created | 0000-00-00 |