Care Leaver Jobs Pilot Self Assessment V1

- Step 1 of 16

This is a self assessment.

Your name.. The Candidate

First

Last

Date of Birth

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About any disabilities you may have?

Do you have any disabilities?

Yes
No
Prefer not to say

Please tell us which disability you have?

Autistic spectrum condition
Hearing impairment
Learning disability
Mental health
Mobility
Progressive / chronic illness
Visual impairment
Wheel chair user
Other

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About your physical health?

Do you have any physical health problems?

Yes
No
Prefer not to say

Please tell us what physical health problems you have?

Breathing problems or chest pain
Cancer
Dental problems
Diabetes
Epilepsy
Eye problems
Fainting / blackouts
Hypertension
Liver problems
Poor foot health
Problems with bones, joints and muscles
Problems with circulation / blood clots
Respiratory
Skin / wound infection
Stomach pain or problems
Urinary problems / infections
Other
Other - do not want to disclose

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About your mental health?

Have you in the past or do you struggle now with your mental health?

Yes
No
Don't not want to dislcose

And when have you struggled with your mental health?

This is ongoing
Previously in the last 12 months
Over 12 months ago
Do not wish to disclose

Please tell us about your mental health struggles now or in the past

Aggressive or violent towards others
Difficulty sleeping
Feel depressed
Hard to control anger
Hear voices
Often feel anxious
Often feel stressed
Panic attacks
Self harm
Suicidal thoughts
Other
Do not with to disclose

Please tell us what other struggles you have with your mental health?

What support would help with your mental health

Activities - arts / volunteering / sport
Medication
Peer support
Practical support with daily life
Service to address dual diagnosis
Specialist mental health worker
Talking therapies e.g. counselling
Something else

Do you have a mental health diagnosis?

Yes
No
Do not wish to disclose

Please tell us about any diagnosis that you have?

ADHD
Anxiety disorder
Asperger’s
Autism
Bipolar disorder
Depression
Dual diagnosis - drug / alcohol problem
Eating disorder
Personality disorder
Phobia
Post-traumatic stress disorder
Schizophrenia
Tourettes
Other mental health diagnosis
Do not wish to disclose

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About any involment with the police or criminal justice system?

Please tell us about any involvement you have ever had?

Had involvement with the police
Has has a reprimand or warning
Involved with probation
Involved with youth justice
Unspent criminal convictions
Spent criminal convictions
Subject to MAPPA arrangements
Served a community penalty
On licence
Have ever served a prison sentance
None of these
Other

Please tell me in your own words what happend?

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About your education, training, employment and volunteering

Your current economic status

Full time student
Full time work (over 24 hours per week)
Government training or work program
Job seeker / looking for work
Long term sick / disabled
Not seeking work
Part time work (under 25 hours per week)
Part time work (zero hours contract)
Other

Please tell us in your own words about your work history?

Please tell us in your own words about your education?

Please tell us in your own words about any training you have done?

Please tell us in your own words about any volunteering you have done?

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About any substance and alcohol usage

Do you currently use drugs or alcohol?

Please tell us what drugs or alcohol you currently use?

Alcohol
Amphetamine / Speed
Benzodiazepines / benzos
Cannabis / weed
Crack / cociane
Heroin
New psychoactive
Prescription drugs
Other

What (non-Prescribed) drugs are you taking, and how much alcohol are you drinking daily.

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1 - Accommodation

Where you live, managing a tenancy, moving on, sharing a place

Please select the statement that applies to you about accommodation

I live independently and manage well enough without support from a service. I know how to get help if I need it
I have somewhere stable to live, or am applying for a place. I mostly manage OK but need some support with the tenancy agreement, sharing with people or other issues
I have somewhere to live, with support, and am not at risk of eviction. I am taking steps to live independently in the future but it’s early days
I am at risk of eviction, staying somewhere unsuitable, homeless or in custody. I engage with support but don’t take the initiative
I am at risk of eviction, staying somewhere unsuitable, homeless or in custody. I don’t have or don’t accept support

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2 - Work and Learning

How you spend your time during the week, aspirations for the future

Please select the statement that applies to you about work and learning

I am in training, education or work, or I’m a full-time parent. I am working towards what I want to achieve without support from a service
I am in training, education or work, or I’m a full-time parent. I need support to maintain this, make progress or change direction
I am having a go at training, education, volunteering, work or an other activity but find it hard to stick to
I am not in work, training or education but I want to do something with my time and am talking with someone about it
I am not in work, training or education and I don't want to talk to anyone about it.

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3 - People and support

Support from workers and networks outside the service

Please select the statement that applies to you about people and support

I mostly feel supported and connected. I have friends or other people outside the service who are good for me, so I don’t need professional support in this area
I am getting to know new people or spending more time with people who are good for me, but I need support from workers too
I try to spend time with people outside the service who are good for me but it’s difficult. People knock me back or I miss my old friends
At least one worker in the service is helping me and I feel supported by them. My friends or family are mostly not helpful
There is no one who cares what happens to me or helps me sort my life out, or I am in a violent relationship or at risk from people around me

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4 - Health

Food, exercise, sleep, doctors, sexual health, mental health

Please select the statement that applies to you about mental health

I look after my physical, mental and sexual health well enough by myself. I go to the doctor when I need to and mostly have enough healthy food, exercise and sleep
I look after my health well enough in some ways but there are areas where I need reminders or support from the service
I am trying to look after my health better, such as by going to the doctor if I am ill or eating more healthy food. It’s difficult and I often slip back into old habits
I am harming or risking my health but I know this needs to change and I am talking to someone about it
I am harming or risking my health by not getting treatment for physical or mental health problems, sexual risk taking or not eating well enough

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5 - How you feel

Knowing who you are, self-esteem, working on any issues with identity

Please select the statement that applies to you about how you feel

I mostly feel confident, know who I am and am happy to be me. I can address any issues around my identity or being accepted without help from the service
I know who I am and mostly feel OK about being me, but need support from the service with some issues or when things go wrong
I have some issues around identity or self-esteem. I am trying to sort them out and I sometimes feel OK about myself but it’s early days
I feel that I don’t fit in, or I’m confused or stressed, but I am talking to someone and getting some help
I feel that I don’t fit in, or I feel stressed or confused or not accepted for who I am. Or I don’t really know who I am. I mostly feel bad about myself

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6 - Choices and behaviour

Drugs and alcohol, avoiding offending and anti-social behaviour

Please select the statement that applies to you about your choices and behaviour

I stay safe, without support. I drink a little or not at all and don’t use illegal drugs. I am not offending or involved in anti-social behaviour
I mostly stay safe and out of trouble but sometimes things go wrong so I need support in this area
I am trying to make positive choices but it’s difficult and things can go wrong
I want to stop being in trouble or am worried about drugs, alcohol or the risky situations I get into. I am talking to someone about making better choices
or the risky situations I get into. I am talking to someone about or drinking too much. I don’t want to discuss my choices or behaviour

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7 - Money and rent

Rent, benefits, grants, banks, budgeting and planning ahead

Please select the statement that applies to you about your money and rent

I am confident managing money safely and responsibly. I deal with any rent arrears or debts and can budget, plan ahead and make decisions without support
I manage money OK and can mostly buy the basic things I need and avoid crises, but there are some problems so I need support
I have some regular income and am trying to sort out problems with money. It’s early days and I often end up in chaos or short of money
I am not managing my money or have no regular income. I go along with help to sort this out but am not taking the initiative
I have no regular income or I’m not managing money responsibly or safely. I am not doing anything about this

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8 - Practical life skills

Shopping, cooking, laundry, cleaning and other practical tasks

Please select the statement that applies to you about practical life skills

I am able to live independently. I am confident with shopping, cooking, cleaning, laundry and other practical tasks
I manage OK with most practical tasks but need support in one or two areas
I am trying to learn to cook or to gain other practical life skills I need to live independently but it’s early days and there’s a lot to take in
I am not able to shop, cook, clean or do laundry or other tasks well enough to look after myself. I go along with support in this area but don’t take the initiative
I am not able to shop, cook, clean or do laundry or other tasks well enough to look after myself. I don’t have or don’t accept support in this area

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We would like to discuss this application with you and the person that is helping you. This person could be a firend, relative, social worker, personal advisor or any other person.

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The Form is correct to the best of my ability. Signature

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