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Clinician's
Client's
Client Assessment
Transition House, Inc. 700 Asp, Suite 2 Norman, OK 73069
CLIENT SCREENING ASSESSMENT
(to be completed by client)
 Updated September 18, 2007 
 
 Name:________________________________________   
 
 Date:____________________
 
 Total Score:______________
Rating scale:
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1 - No ability     

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2 - Minimal ability     

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3 - Some difficulty, average

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4 - Usually able, above average     

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5 - Consistently able, excellent

DAILY LIVING SKILLS:                  

RATING:
1.  Using the bank,
 1    2    3    4    5
2.  Budgeting, paying bills
 1    2    3    4    5
3.  Shopping
 1    2    3    4    5
4.  Cooking
 1    2    3    4    5
5.  Maintaining a clean home
 1    2    3    4    5
6.  Doing laundry
 1    2    3    4    5
7.  Hygiene (body, teeth, etc.)
 1    2    3    4    5
8.  Medication use
 1    2    3    4    5
9.  Interviewing skills
 1    2    3    4    5
10. Attendance & punctuality
 1    2    3    4    5
11. Working well with others
 1    2    3    4    5
12. Following instructions
 1    2    3    4    5
13. Ride the bus
 1    2    3    4    5
14. Find ways to get around
 1    2    3    4    5
15. Find and use community services
 1    2    3    4    5
16. Able to occupy free time
 1    2    3    4    5
17. Make plans and carry them out with others
 1    2    3    4    5

 

 

PERSONAL & INTERPERSONAL SKILLS:

RATING:
18. Ability to identify and understand problem areas
 1    2    3    4    5
19. Knowing when to ask for help and ability to do so
 1    2    3    4    5
20. Able to control impulses and manage behavior
 1    2    3    4    5
21. Communication skills
 1    2    3    4    5
22. Manage feelings
 1    2    3    4    5
23. Form and maintain relationships
1    2    3    4    5
24. Initiate contact with others
1    2    3    4    5
25. Have fun
1    2    3    4    5