MG Intake/Assessment Form
Form should be completed upon initial assessment/meeting with potential MG client to determine eligibility and motivation
of client to become self-sufficient.
CIRCLE:
Refugee
Asylee
Cuban/Haitian Entrant
Victim of Trafficking
Date of MG Assessment/Intake: ____________ Date of MG Eligibility: _____________ Day 31: ______________
Name (List PA First)
DOB
Alien #
Relationship
Employable
Y/N
1.
PA
2.
3.
4.
5.
6.
7.
Native Language: ________________ Additional Languages Spoken: ________________________________
Obstacles to Employment (fill in all that apply)
1. How many employable clients are in the case? _________________________________________________________
2. Can the case be split into multiple units? ____________________ MG and Non-MG units? _____________________
3. Is the client physically and mentally healthy to work? ___________________________________________________
4. Is the client motivated to work? _____________________________________________________________________
a.
What skills do they have? ___________________________________________________________________
________________________________________________________________________________________
b. Were they previously employed? _____________________________________________________________
c.
Are they flexible about work/hours/commuting? _________________________________________________
d. What types of jobs are/aren’t they willing to do? _________________________________________________
e.
What are their salary expectations? ____________________________________________________________
f.
What is their attitude about the MG Program and early self-sufficiency? ______________________________
________________________________________________________________________________________
g. Does the client understand that he/she must not access any other form of public cash assistance while in the MG Program
th
(180
Day)? __________________________________________________________________
5. Does the client speak English? _____________________________________________________________________
a.
Is their English level sufficient for entry level employment? ________________________________________
b. Will the client attend ESL classes concurrently with employment? ___________________________________
6.
Does the client have a support network in the US (Relatives, Friends, church, etc)?
_______________________________________________________________________________________________
a.
What assistance are they receiving? ___________________________________________________________
________________________________________________________________________________________
b.
Are they receiving services from another agency? What? __________________________________________
________________________________________________________________________________________
7. Is the client paying rent? _________________ How much? _______________________________________________
a.
What is the client’s housing situation? _________________________________________________________
MG POSITIVE ASSESSMENT: __________ DOE: _________________ MG NEGATIVE ASSESSMENT: _________
Case # ___________
Address______________________________________________________ City______________ zip Code____________
Telephone #______________________________
Alternate Telephone #______________________________