Casey Life Skills Assessment

1Basic Information

2Daily Living

3Self Care

4Relationships and Communication

5Housing & Money Management

6Work and Study Life

7Career and Education Planning

8Looking Forward

9Confirmation

Name

First Last

Please Select your Advocate

Date Assessment is being Completed

MM slash DD slash YYYY

Daily Living

Are the following statements like me

I know where to go to get on the Internet.

Mostly No

Somewhat

Mostly Yes

Yes

I can find what I need on the Internet.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to use my email account.

Mostly No

Somewhat

Mostly Yes

Yes

I can create, save, print, and send computer documents.

Mostly No

Somewhat

Mostly Yes

Yes

I know the risks of meeting someone in person that I met online.

Mostly No

Somewhat

Mostly Yes

Yes

I would not post pictures or messages if I thought it would hurt someone's feelings.

Mostly No

Somewhat

Mostly Yes

Yes

If someone sent me messages online that made me feel bad or scared, I would know what to do or who to tell.

Mostly No

Somewhat

Mostly Yes

Yes

I know at least one adult, other than my worker, who would take my call in the middle of the night if I had an emergency.

Mostly No

Somewhat

Mostly Yes

Yes

An adult I trust, other than my worker, checks in with me regularly.

Mostly No

Somewhat

Mostly Yes

Yes

When I shop for food, I take a list and I compare prices.

Mostly No

Somewhat

Mostly Yes

Yes

I can make meals with or without using a recipe.

Mostly No

Somewhat

Mostly Yes

Yes

I think about what I eat and how it impacts my health.

Mostly No

Somewhat

Mostly Yes

Yes

I understand how to read food product labels to see how much fat, sugar, salt, and calories the food has.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to do my own laundry.

Mostly No

Somewhat

Mostly Yes

Yes

I keep my living space clean.

Mostly No

Somewhat

Mostly Yes

Yes

I know the products to use when cleaning the bathroom and kitchen.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to use a fire extinguisher.

Mostly No

Somewhat

Mostly Yes

Yes

Self Care

Are the following statements like me

I can take care of my own minor injuries and illnesses.

Mostly No

Somewhat

Mostly Yes

Yes

I can get medical and dental care when I need it.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to make my own medical and dental appointments.

Mostly No

Somewhat

Mostly Yes

Yes

I know when I should go to the emergency room instead of the doctor’s office.

Mostly No

Somewhat

Mostly Yes

Yes

I know my family medical history.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to get health insurance when I am older than 18.

Mostly No

Somewhat

Mostly Yes

Yes

I have at least one trusted adult who would visit me if I were in the hospital.

Mostly No

Somewhat

Mostly Yes

Yes

There is at least one adult I trust who would be legally allowed to make medical decisions for me and advocate for me if I was unable to speak for myself.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to get the benefits I am eligible for, such as Social Security, Medicaid, Temporary Assistance for Needy Families (TANF), and Education and Training Vouchers (ETV).

Mostly No

Somewhat

Mostly Yes

Yes

I bathe (wash up) daily.

Mostly No

Somewhat

Mostly Yes

Yes

I brush my teeth daily.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to get myself away from harmful situations.

Mostly No

Somewhat

Mostly Yes

Yes

I have a place to go when I feel unsafe.

Mostly No

Somewhat

Mostly Yes

Yes

I can turn down a sexual advance.

Mostly No

Somewhat

Mostly Yes

Yes

I know ways to protect myself from sexually transmitted diseases (STDs).

Mostly No

Somewhat

Mostly Yes

Yes

I know how to prevent getting pregnant or getting someone else pregnant.

Mostly No

Somewhat

Mostly Yes

Yes

I know where to go to get information on sex or pregnancy.

Mostly No

Somewhat

Mostly Yes

Yes

Relationships and Communication

Are the following statements like me

I can speak up for myself.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to act in social or professional situations.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to show respect to people with different beliefs, opinions, and cultures.

Mostly No

Somewhat

Mostly Yes

Yes

I can describe my racial and ethnic identity.

Mostly No

Somewhat

Mostly Yes

Yes

I can explain the difference between sexual orientation and gender identity.

Mostly No

Somewhat

Mostly Yes

Yes

I have friends I like to be with who help me feel valued and worthwhile.

Mostly No

Somewhat

Mostly Yes

Yes

I am a part of a family and we care about each other.

Mostly No

Somewhat

Mostly Yes

Yes

I can get in touch with at least one family member when I want to.

Mostly No

Somewhat

Mostly Yes

Yes

I have friends or family to spend time with on holidays and special occasions.

Mostly No

Somewhat

Mostly Yes

Yes

I know at least one adult I can depend on when I exit care.

Mostly No

Somewhat

Mostly Yes

Yes

I know an adult who could be a grandparent, aunt or uncle to my children now or my future children.

Mostly No

Somewhat

Mostly Yes

Yes

My relationships are free from hitting, slapping, shoving, being made fun of, or name calling.

Mostly No

Somewhat

Mostly Yes

Yes

I know the signs of an abusive relationship.

Mostly No

Somewhat

Mostly Yes

Yes

I know what my legal permanency goal is.

Mostly No

Somewhat

Mostly Yes

Yes

I have information about my family members.

Mostly No

Somewhat

Mostly Yes

Yes

I think about how my choices impact others.

Mostly No

Somewhat

Mostly Yes

Yes

I can deal with anger without hurting others or damaging things.

Mostly No

Somewhat

Mostly Yes

Yes

I show others that I care about them.

Mostly No

Somewhat

Mostly Yes

Yes

Housing & Money Management

Are the following statements like me

I understand how interest rates work on loans or credit purchases.

Mostly No

Somewhat

Mostly Yes

Yes

I understand the disadvantages of making purchases with my credit card.

Mostly No

Somewhat

Mostly Yes

Yes

I know the importance of a good credit score.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to balance my bank account.

Mostly No

Somewhat

Mostly Yes

Yes

I put money in my savings account when I can.

Mostly No

Somewhat

Mostly Yes

Yes

I know an adult who would help me if I had a financial emergency.

Mostly No

Somewhat

Mostly Yes

Yes

I use online banking to keep track of my money.

Mostly No

Somewhat

Mostly Yes

Yes

I know the advantages and disadvantages of using a check cashing or payday loan store.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to find safe and affordable housing.

Mostly No

Somewhat

Mostly Yes

Yes

I can figure out the costs to move to a new place, such as deposits, rents, utilities, and furniture.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to fill out an apartment rental application.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to get emergency help to pay for water, electricity, and gas bills.

Mostly No

Somewhat

Mostly Yes

Yes

I know what can happen if I break my rental lease.

Mostly No

Somewhat

Mostly Yes

Yes

I can explain why people need renter’s or homeowner’s insurance.

Mostly No

Somewhat

Mostly Yes

Yes

I know an adult I could live with for a few days or weeks if I needed to.

Mostly No

Somewhat

Mostly Yes

Yes

There is at least one adult that I have regular contact with, other than my case manager or other professional, who lives in stable and safe housing.

Mostly No

Somewhat

Mostly Yes

Yes

I know an adult I can go to for financial advice.

Mostly No

Somewhat

Mostly Yes

Yes

I plan for the expenses that I must pay each month.

Mostly No

Somewhat

Mostly Yes

Yes

I keep records of the money I am paid and the bills I pay.

Mostly No

Somewhat

Mostly Yes

Yes

I know what happens in my state if I am caught driving without car insurance or a driver’s license.

Mostly No

Somewhat

Mostly Yes

Yes

I can explain how to get and renew a driver’s license or state ID card.

Mostly No

Somewhat

Mostly Yes

Yes

I can figure out all the costs of car ownership, such as registration, repairs, insurance, and gas.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to use public transportation to get where I need to go.

Mostly No

Somewhat

Mostly Yes

Yes

Work and Study Life

Are the following statements like me

I know how to develop a resume.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to fill out a job application.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to prepare for a job interview.

Mostly No

Somewhat

Mostly Yes

Yes

I know what the information on a pay stub means.

Mostly No

Somewhat

Mostly Yes

Yes

I can fill out a W-4 payroll exemption form when I get a job.

Mostly No

Somewhat

Mostly Yes

Yes

I know what employee benefits are.

Mostly No

Somewhat

Mostly Yes

Yes

I know what sexual harassment and discrimination are.

Mostly No

Somewhat

Mostly Yes

Yes

I know the reasons why my personal contacts are important for finding a job.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to get the documents I need for work, such as my Social Security card and birth certificate.

Mostly No

Somewhat

Mostly Yes

Yes

I know how and when I can see my child welfare or juvenile justice records.

Mostly No

Somewhat

Mostly Yes

Yes

I know an adult who will go with me if I need to change schools.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to get help from my school’s mental health services.

Mostly No

Somewhat

Mostly Yes

Yes

I know where I can get help with an income tax form.

Mostly No

Somewhat

Mostly Yes

Yes

I have an adult in my life who cares about how I am doing at school or work.

Mostly No

Somewhat

Mostly Yes

Yes

I can take criticism and direction at school or work without losing my temper.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to prepare for exams and/or presentations.

Mostly No

Somewhat

Mostly Yes

Yes

I know where I can get tutoring or other help with school work.

Mostly No

Somewhat

Mostly Yes

Yes

I look over my work for mistakes.

Mostly No

Somewhat

Mostly Yes

Yes

I get to school or work on time.

Mostly No

Somewhat

Mostly Yes

Yes

I get my work done and turned in on time.

Mostly No

Somewhat

Mostly Yes

Yes

Career and Education Planning

Are the following statements like me

I know how to find work-related internships.

Mostly No

Somewhat

Mostly Yes

Yes

I know where to find information about job training.

Mostly No

Somewhat

Mostly Yes

Yes

I can explain the benefits of doing volunteer work.

Mostly No

Somewhat

Mostly Yes

Yes

I have recently talked to an adult who works in a job I would like to have.

Mostly No

Somewhat

Mostly Yes

Yes

I know what type (college, trade school) education I need for the work I want to do.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to get into the school, training, or job I want after high school.

Mostly No

Somewhat

Mostly Yes

Yes

I know how to find financial aid to help pay for my education or training.

Mostly No

Somewhat

Mostly Yes

Yes

I have talked about my education plans with an adult who cares about me.

Mostly No

Somewhat

Mostly Yes

Yes

I know an adult who will help me apply for training or education after high school.

Mostly No

Somewhat

Mostly Yes

Yes

Looking Forward

Are the following statements like me

I believe I can influence how my life will turn out.

Mostly No

Somewhat

Mostly Yes

Yes

I can describe my vision for myself as a successful adult.

Mostly No

Somewhat

Mostly Yes

Yes

I have a good relationship with a trusted adult I like and respect.

Mostly No

Somewhat

Mostly Yes

Yes

I would like to use my experience to help other youth.

Mostly No

Somewhat

Mostly Yes

Yes

I believe my relationships with others will help me succeed.

Mostly No

Somewhat

Mostly Yes

Yes

I feel I am ready for the next phase of my life.

Mostly No

Somewhat

Mostly Yes

Yes

Most days, I am proud of the way I am living my life.

Mostly No

Somewhat

Mostly Yes

Yes

Most days, I feel I have control of how my life will turn out.

Mostly No

Somewhat

Mostly Yes

Yes

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