MFA Client Comprehensive Assessment
The MFA Assessment is used to better get to know you. By understanding what you have done, where you are now, and where you want to go, MFA can assist with a pathway to success! Start below and let's get to the finish line together!
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Email *
Client Email Address *
First Name *
Last Name *
Last 4 Digits of Social Security Number *
Social/Personal/Financial
These questions are about your current social, personal and financial situation. Please answer to the best of your ability.
Current Marital Status *
State or Federal Benefits *
Required
Do you feel you have an adequate support system for you and your family? *
Required
Do you have any outstanding Financial Obligations (i.e. Student Loans, Rent, Medical Bills, Court Fines, etc.) *
Are you currently receiving any agency/organization services (social services, mental health, community services, disability, etc.) If so, what are they and what is the name of the agency/agencies? *
Childcare
These questions ask about current and future childcare needs?
How many children do you have under the age of 18 years and state which children live with you? *
Do you have appropriate Childcare? *
What are your current Childcare Needs? *
Housing
These questions are related to current and future Housing needs.
Do you own your own home or rent? *
Is your rent or mortgage affordable? *
Do you share costs with others living in your home? If so, please explain costs you share.
Have you recently relocated to Virginia? If so, when did you move to Virginia?
List all localities in which you have lived in the past 5 years. (i.e. Petersburg, Chesterfield, Richmond, etc.) *
What are your current Housing Needs? *
Healthcare
These questions assess any past or current Healthcare issues/needs.
Do you have Medical Insurance for you and your family? *
Required
Are you currently being treated for any Healthcare issues which may affect your participation/progress or completion in an education/training program or from obtaining employment? If so, please explain. *
How would you rate your current Health? *
No Health Concerns
Ongoing Health Issues interfering with everyday activities
Education/Training
Please answer each question to the best of your ability regarding your past, current or future Education and Training.
What is your Current Career Interest? *
Will you need additional education or training skills to pursue your Career Interest? *
What is the highest grade you have achieved? *
List Skills obtained in Past Education/Training Experience  (i.e. Food Service/Cook, Retail Sales, Security, Machine Operator, Housekeeping, Home Health, etc.) *
Employment
Please answer the questions related to past, current, and future Employment.
Do you have appropriate work attire? *
Are you currently Employed? If so, what is the name of the business and what is your position? *
If you are not Employed, why are you not Working? Mark all that apply. *
Required
Would you say you have a poor work history? Are there "gaps" in your work history? If so, why? *
Have you ever been fired/let go from a job? *
Are you currently receiving Unemployment Insurance (UI)? *
Are you Employed in your chosen Career? If not what do you need to move into your chosen Career? *
How do you rate your current level of Computer Skills? *
Excellent Computer Skills
Very Little Experience on the Computer
Do you have reliable Transportation for Work? *
Do you Own your own Car? *
Do you have a Current Driver's License? *
If you do not have a Current Driver's License, what do you need to do to get a Current Driver's License? Mark all that apply. *
Required
Do you use the public bus for transportation needs? *
Background
Please answer these questions that relate to current and/or past court involvement and/or Drug use?
Have you ever been Arrested for a Criminal charge? If so, what was the charge and when were you arrested? *
Do you have any current Criminal Charges or pending Court Dates? If so, what are the charges and when are the Court Dates? *
Are you currently on Probation or Parole? If so, which jurisdiction/locality? *
Do you have any Court Fines/DMV Fines? If so, how much do you owe? *
If given a Drug Screen today, would you pass the screen? *
Are you currently receiving any services for Alcohol/Substance Abuse? *
If receiving Alcohol/Substance Abuse Services, how do you feel your recovery may be affected by training/and or employment? *
Would you like to speak with a Counselor for current Needs (i.e. Mental Health, Family, Alcohol, Substance use issues, etc.)? *
Individual Comprehensive Summary
(To be Completed by MFA Staff)
Participant Signature: By signing below you are verifying the information you provided is true and correct to the best of your ability. *
MFA Staff Signature/Date: Verifies Assessment has been reviewed with the MFA Participant.
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