Client ID: ____________________

Assessment Date: ____________________

Self-Sufficiency Matrix Agency Completing

Form: ______________________________
Staff Name: _________________________

Rate the client’s level of self-sufficiency at the assessment point-in-time on a scale of 1 to 6 in each domain
below on the descriptions provided. Select ‘Not Applicable’ if a domain is not applicable for the client. One
for each Head of Household only.

Identification – All fields required unless otherwise noted

First Name: _______________________________ Middle Name: _______________________
Last Name: _______________________________ Suffix: _____________________________
Social Security Number (SSN): ____-___-____
Birth Date (DOB): ____/____/____
Self Sufficiency Assessment
Domain Descriptions
Income ☐ 1. No Income
☐ 2. Inadequate income and/or spontaneous or inappropriate spending
☐ 3. Can meet basic needs with subsidy, appropriate spending
☐ 4. Can meet basic needs and manage debt without assistance
☐ 5. Income is sufficient, well managed, has discretionary income and is able to save
☐ 6. Not applicable
Employment ☐ 1. No job
☐ 2. Temporary, part-time or seasonal, inadequate pay, no benefits
☐ 3. Employment full-time, inadequate pay; few or no bills
☐ 4. Employed Full-time with adequate pay and benefits
☐ 5. Maintains permanent employment with adequate income and benefits
☐ 6. Not applicable
Housing ☐ 1. Homeless or threatened with an eviction
☐ 2. In transitional, temporary or substandard housing, an/or current* rent/mortgage is
unaffordable
☐ 3. In stable housing that is safe but only marginally adequate
☐ 4. Household is safe, adequate, subsidized housing
☐ 5. Household is safe, adequate, unsubsidized housing
☐ 6. Not applicable
Food ☐ 1. No food or meant to prepare it. Relies to a significant degree on other sources of free
or low-cost food
☐ 2. Household is on food stamps
☐ 3. Can meet basic food needs but requires occasional assistance
☐ 4. Can meet basic food needs without assistance
☐ 5. Can choose to perchance any food household desires
☐ 6. Not applicable
Childcare ☐ 1. Needs childcare, but none is available/accessible and/or child is not eligible
☐ 2. Childcare is unreliable or unaffordable; inadequate supervision is a problem for
childcare
☐ 3. Affordable subsidized childcare is available but limited
☐ 4. Reliable subsidized childcare is available; no need for subsidies
☐ 5. Able to select quality childcare of choice
☐ 6. Not applicable

HMIS v 18 (10/2025) Page 1 of 4

 Children’s Education ☐ 1. One or more eligible children not enrolled in school
☐ 2. One or more eligible children enrolled in school but not attending classes
☐ 3. Enrolled in school, but one or more children only occasionally attending classes
☐ 4. Enrolled in school and attending classes most of the time
☐ 5. All eligible children enrolled and attending on a regular basis
☐ 6. Not applicable
Adult Education ☐ 1. Literacy problems and/or no high school diploma/GED are serious barriers to
employment
☐ 2. Enrolled in literacy and/or GED program and/or has sufficient command of English to
where language is not a barrier to employment
☐ 3. Has high school diploma/GED
☐ 4. Needs additional education/training to improve employment situation and/or to
resolve literacy problems to where they are able to function effectively in society
☐ 5. Has completed education/training needed to become employable. No literacy
problems
☐ 6. Not applicable
Legal ☐ 1. Current outstanding tickets or warrants or other serious unresolved legal issues
☐ 2. Current charges/trial pending; noncompliance with probation/parole/legal issues
impacting housing qualifications
☐ 3. Fully compliant with probation/parole terms/ past non-violent felony convictions/
working on plan to resolve other legal issues
☐ 4. Has successfully completed probation/parole with past 12 months, no new charges
filed; recently resolved other legal issues
☐ 5. No felony criminal history and/or no active criminal justice involvement in more than
12 months
☐ 6. Not applicable
Health Care ☐ 1. No medical coverage with immediate need
☐ 2. No medical coverage and great difficulty accessing medical care when needed. Some
household members may be in poor health
☐ 3. Some members (e.g. children) on Medicaid or other state-sponsored health insurance
program
☐ 4. All members can get medical care when needed but may strain budget
☐ 5. All members are covered by affordable, adequate health insurance
☐ 6. Not applicable
Life Skills ☐ 1. Unable to meet basic needs such as hygiene, food, activities of daily living
☐ 2. Can meet a few but not all needs of daily living without assistance
☐ 3. Can meet most but not all needs of daily living without assistance
☐ 4. Able to meet all basic needs of daily living without assistance
☐ 5. Able to provide beyond basic needs of daily living of self and family
☐ 6. Not applicable
Mental Health ☐ 1. Danger to self or others, recurring suicidal ideation; experiencing severe difficulty in
day-to-day life due to psychological problems
☐ 2. Recurrent mental symptoms that may affect behavior but not a danger to self/others;
persistent problems with functioning due to mental health symptoms
☐ 3. Mild symptoms may be present but are transient; only moderate difficulty in
functioning due to mental health problems
☐ 4. Minimal symptoms that are expectable responses to life stressors; only slight
impairment in functioning
☐ 5. Symptoms are absent or rare; good or superior functioning in wide range of activities;
no more that everyday problems or concerns
☐ 6. Not applicable

HMIS v 18 (10/2025) Page 2 of 4

 Substance Abuse ☐ 1. Meets criteria for severs abuse/dependence; resulting problems so severe that
institutional living or hospitalization may be necessary
☐ 2. Meets the criteria for dependence; preoccupation with use and/or obtaining
drugs/alcohol; withdrawal or withdrawal avoidance behaviors evident; use results in
avoidance or neglect of essential life activities
☐ 3. Use within last 6 months; evidence of persistent or recurrent social, occupational,
emotional, or physical problems related to use (such as disruptive behavior or housing
problems); problems that have persisted for at least one month
☐ 4. Client has used during last 6 months but no evidence of persistent or recurrent social,
occupational, emotional, or physical problems related to use; no evidence of recurrent
dangerous use
☐ 5. No drug use/alcohol abuse in last 6 months
☐ 6. Not applicable
Family Relations ☐ 1. Lack of necessary support from family or friends; abuse (DV, child) is present or there
is child neglect
☐ 2. Family/friends may be supportive but lack ability or resources to help; family
members do not relate well with one another, potential for abuse or neglect
☐ 3. Some support from family/friends; family members acknowledge and seek to change
negative behaviors; are learning to communicate and support
☐ 4. Strong support from family or friends; household members support each other’s
efforts
☐ 5. Has healthy/expanding support network; household is stable, and communication is
consistently open
☐ 6. Not applicable
Mobility ☐ 1. No access to transportation, public or private; may have car that is inoperable
☐ 2. Transportation is available but unreliable, unpredictable, unaffordable; may have car
but no insurance, license, etc.
☐ 3. Transportation is available and reliable but limited and/or inconvenient, drivers are
licenses and minimally insured
☐ 4. Transportation is generally accessible to meet basic travel needs
☐ 5. Transportation is readily available and affordable; car is adequately
☐ 6. Not applicable
Community ☐ 1. Not applicable due to crisis situation; in ‘survival mode’
Involvement ☐ 2. Socially isolated and/or no social skills and/or lacks motivation to become involved
☐ 3. Lacks knowledge of ways to become involved
☐ 4. Some community involvement (advisory group, support group) but has barriers such
as transportation, childcare issues
☐ 5. Actively involved in community
☐ 6. Not applicable
Safety ☐ 1. Home or residence is no safe; immediate level of lethality is extremely high; possible
CPS involvement
☐ 2. Safety is threatened/temporary production is available; level of lethality is high
☐ 3. Current level of safety is minimally adequate; ongoing safety planning is essential
☐ 4. Environment is safe, however, future of such is uncertain; safety planning is important
☐ 5. Environment is apparently safe and stable
☐ 6. Not applicable
Parenting Skills ☐ 1. There are safety concerns regarding parenting skills
☐ 2. Parenting skills are minimal
☐ 3. Parenting skills are apparent but not adequate
☐ 4. Parenting skills are adequate
☐ 5. Parenting skills are well developed
☐ 6. Not applicable
HMIS v 18 (10/2025) Page 3 of 4
 Credit History ☐ 1. No credit history
☐ 2. Outstanding judgements or bankruptcy/foreclosure
☐ 3. Has a credit repair plan
☐ 4. Moderate credit rating
☐ 5. Good credit/manageable debt ratio
☐ 6. Not applicable

Matrix Score Summary – The Matrix Score calculates the average of all domain scores between and 5, excluding
domains where ‘Not Applicable’ is selected.

Matrix Score: _________

HMIS v 18 (10/2025) Page 4 of 4