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Self Sufficiency Matrix
The purpose of this form is for Goodwill Chattanooga to be able to review different areas of employee's lives to help provide resources in areas of need. Please contact Rachel Inman at (423) 629-2501 x 3135 or Michelle Kenemore at (423) 629-2501 x 2960 with any questions.
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Date
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MM
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First and Last Name
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Your answer
Store Location
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Your answer
Food and Nutrition
No access to food or means to prepare it
Relies solely on food stamps or other public assistance
Able to meet basic food needs with occasional assistance
Can provide food for the household based solely on the household income
Able to purchase any food wanted by the household
Clear selection
Shelter and Housing
Homeless or threatened with eviction
In temporary or transitional housing
Safe and stable housing; subsidized or over 30% of the household income
Housing is safe, affordable, and unsubsidized
Homeownership
Clear selection
Finance and Income
No income
Not earning enough to cover bills and/or inappropriate spending
Meet basic needs with subsidy and appropriate spending
Meet basic needs and managed debt without assistance
Income is sufficient and discretionary available (savings, retirement, etc.)
Clear selection
Transportation
No access to transportation
Transportation is limited or unreliable
Transportation is available through 3rd party sources
Transportation is reliable and available
Vehicle ownership
Clear selection
Life Skills
Unable to meet basic needs (i.e. hygiene, food, daily living activities, etc.)
Can meet a few but not all needs of daily living without assistance.
Can meet most (but not all) daily living needs without assistance
Able to meet all daily living needs without assistance
Able to provide beyond basic needs of daily living for self and family
Clear selection
Adult Education
No HS diploma or GED/HiSET, literacy or language barrier
Enrolled in literacy, language, and/or GED/HiSET program
Has HS diploma, GED, or HiSET
Needs additional education or training to improve sufficiency
Has completed all education and training needed for employment
Clear selection
Healthcare Coverage
No medical coverage with immediate need
No medical coverage with no immediate need; has difficulty getting medical help when needed
Enrolled in Medicaid and/or Medicare
Enrolled in private insurance, but medical needs may strain the budget
Has insurance that is affordable, adequate, and able to meet medical needs with no strain to budget
Clear selection
Substance Use
Meets criteria for sever abuse/dependence; resulting in problems that institutional living or hospitalization may be necessary
Meets criteria for dependence; preoccupation with use and/or obtaining drugs/alcohol; withdrawal or avoidant behavior or neglect of essential life activities
Use within the last 6 months; evidence of persistent or recurrent social, occupational, emotional, or physical problems related to use (disruptive behavior, housing problems, etc.) have persisted for at least 1 month.
Use within the last 6 months but no evidence of persistent or recurrent social, occupational, emotional, or physical problems
No drug/alcohol abuse in the last 6 months
Clear selection
Mental Health/Safety
Danger to self and/or others, experiencing severe difficulty in day-to-day life
Recurrent mental health symptoms that can impact behavior without being a danger to others
Mild symptoms present, but are brief, with moderate difficulty in day-to-day life
Minimal symptoms with slight impairment in day-to-day functioning typically due to life stressors
Absent or rare mental health symptoms are present; enjoys a wide range of activities with daily life stressors
Clear selection
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