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					                                                                     LIFE SKILLS ASSESSMENT
INDIVIDUAL'S NAME:                                                            COMPLETED BY:                             TITLE:

FUNDING:                                                                      DATE:

SKILLS                                                          SKILL LEVEL
                                                                N/A = Not applicable
                                                                0 = Total support needed
                                                                1 = Regular/ongoing support and/or assistance needed
                                                                2 = Periodic support/assistance needed
                                                                3 = Independent

PERSONAL CARE:                                                  Enter Score                     Comments
Showering/bathing
Oral hygiene
Grooming-including hair and nail care
Bathroom/toileting independence
Dressing
Eating and drinking
Selecting appropriate clothing (to weather/clean)

                                                Actual Score:               0 Possible score:                      21            Percentage:   0%

                                                                                                Comments
Menstrual care, if applicable
Transfers self from wheelchair, if applicable
MEAL PREPARATION                                                Enter Score                     Comments
Uses appliances correctly/safely (stove, oven, microwave)
Plan meals
Plans nutritionally sound meals
Simple food preparation
Able to prepare nutritious meal
Able to follow recipes
Can develop a shopping list
Grocery shopping
Proper food storage
Identifying/disposing of spoiled food
Dishwashing

                                                Actual score:               0 Possible score:                      33            Percentage:   0%



    2006 Imagine!                                                                  1
                                                                     LIFE SKILLS ASSESSMENT
HOUSEHOLD SKILLS:                                                Enter Score                   Comments
Knows when cleaning is needed
Ability to clean including using equipment/cleaners safely
Laundry
Changing and making bed
Keeps surfaces free of dirt and clutter

                                                 Actual Score:             0 Possible score:              15   Percentage:   0%

MONEY MANAGEMENT:                                                Enter Score                   Comments
Demonstrates understanding of function of money
Understands values of coins/bills
Is able to use money to make purchases
Is able to manage own money
Is able to manage bills and correspondence
Uses checking/savings account responsibly
Is able to access bank
Is able to budget
Is able to follow budget
Functional number skills
Paying bills promptly

                                                 Actual score:             0 Possible score:              33   Percentage:   0%

COMMUNITY USE/SURVIVAL:                                          Enter Score                   Comments
Can state name, address, phone number
Knows what to do if lost
Pedestrian skills--knows signs
Asks for help if needed
Is able to access neighborhood resources
Is able to access larger community resources
Is able to use public transportation
Reacts cautiously with strangers

                                                 Actual score:             0 Possible score:              24   Percentage:   0%

LEISURE:                                                         Enter Score                   Comments
Has hobbies or leisure interests
Management of unstructured time
Participates in social/recreational activities
Accesses social/recreational activities

                                                 Actual score:             0 Possible score:              12   Percentage:   0%

    2006 Imagine!                                                                2
                                                                 LIFE SKILLS ASSESSMENT
COMMUNICATION:                                               Enter Score                   Comments
Is able to make needs knows
Is able to express preferences
Can usually be understood by others
Is able to use the telephone
Functional reading
Functional writing
Knows days of the week/use of calendar
Use of communication augmentation, if applicable

                                             Actual score:             0 Possible score:              24   Percentage:   0%

SOCIAL/BEHAVIORAL SKILLS:                                    Enter Score                   Comments
Shows respect for others
Responsive to requests by others
Manners/Courtesy
Caring for own and other’s property
Takes responsbilitiy for actions
Is able to cope during stressful situations
Is able to cope with change
Has effective problem-solving skills
Is able to make decisions
Is able to tell time
Is timely for appointments
Makes new friends
Is able to accept constructive criticism
Is able to follow directions/instructions
Is able to understand cause and effect
Is able to engage in give and take relationships

                                             Actual score:             0 Possible score:              48   Percentage:   0%

DESCRIBE ANY ADDITIONAL PHYSICAL OR COGNITIVE BARRIERS:




    2006 Imagine!                                                            3

				
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