Living Advantage Assessment 1A

Contact Information: Date:_____________________
First Name:_______________________MI:____ Last:_________________________________
Date of Birth:_____________ Age___Grade Level/Year of College:____________________

Which best describes you?
Male Female Other____________________________
Which best describes you?
African/Caribbean/Black Latino/Chicano/Hispanic Asian/Pacific Islander Middle-Eastern
Caucasian/European/White Tribal/Native American South-Asian/Indian Multiracial
Where are you currently staying?
Address:__________________________________City:__________________________________
State: _________ Zip: ________________
Please provide the best contact information for you.
Cell ________________________________Home#::______________________________________
Email: ___________________________________________________________________________
Alternate E-mail: ________________________________________________________________
Twitter Name:____________________________Facebook Name:_________________________
*May Living Advantage Friend you on Twitter? ( )Yes ( )No
*May Living Advantage friend you on Facebook? ( )Yes ( )No
Mark your current living situation
( )Live with Parent/Relative ( )Kinship Care(KinGAP) ( )Foster Home ( )Transient/Homeless ( )Probation/Criminal Justice Placement ( )Rent/Own independent housing
Group Home (Name)_______________________________________________________________
Transitional Housing( Name)______________________________________________________
Please provide us with persons to contact who would know where you were in case we cannot reach you, or in case of an emergency.
Name:___________________________________Relationship to you:______________________
Phone:__________________________________Email:_________________________________
Name:___________________________________Relationship to you:______________________
Phone:__________________________________Email: __________________________________
Name:___________________________________Relationship to you:______________________
Phone:__________________________________Email:____________________________________

______________
Revised 10/09/2015 2
Date: __________________
Are you currently enrolled in school?
Out of school/Did not complete Obtained Vo/Tech Certificate__________________________________
Attending Middle School Attending 2-year College
Attending High School Completed Associate’s Degree________________________________
Completed GED Attending 4-year College
Completed High School Completed Bachelor’s Degree_________________________________
Attending Vocational School Attending Graduate School
Completed Graduate School________________________________
If Yes: School Name: __________________________________________________________________________
Address: ________________________________________________________________City: ___________________________________
State: _________ Zip: ________________
Do you feel confident you will graduate from this school? Yes No
Do you participate in any extra curricular activities in and/or out of school? Yes No
Please list.
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Do you have any children? Currently Pregnant Yes No
If yes, how many? _______Sons, _______Daughters
Have you ever been in foster care? Yes No
If yes, were you in foster care at age 16 or older? Yes No
How many foster/group home placements have you been in? _______________
Have you ever been involved in the juvenile justice system?
Never involved In-custody On probation On Parole Discharged as youth
Discharged as adult
If yes, how many times have you been adjudicated? _______________
Are you ILP eligible? Yes No Don’t Know NOT foster/probation
If Yes, Have you ever worked with an ILP Coordinator? Yes No
If Yes, How many ILP coordinators have you worked with? _______________
#______________
Revised 10/09/2015 3
Date: __________________
Please indicate if you have the following:
ILP Coordinator’s Name ______________________________________________ Phone:_____________________________
Email: ______________________________________________ Not Applicable
Social Worker’s Name _______________________________________________ Phone:_____________________________
Email: ______________________________________________ Not Applicable
Parole/Probation Worker’s Name______________________________________ Phone:_____________________________
Email: ______________________________________________ Not Applicable
Lawyer’s Name_____________________________________________________ Phone:_____________________________
Email: ______________________________________________ Not Applicable

Social Security Card Yes No Birth Certificate Yes No
Immigration Papers Yes No N/A School Records/Degrees Yes No
Immunization Card Yes No Legal Papers Yes No N/A
Worker’s permit Yes No N/A DCFS/Custody Papers Yes No N/A
CA Driver’s License Yes No N/A Photo ID Yes No
Would you like Living Advantage to help you acquire any of the above records? Yes No
Would you like Living Advantage to help you securely store any of the above records? Yes No
Please check all the services below you would be interested in receiving:
Employment Yes No
Education Yes No
Housing Yes No
Food Yes No
Health Care Yes No
Transportation Yes No
Child care Yes No
Community Service Yes No
Mobile phone/Voicemail Yes No
Would you like a mentor? Yes No
*Please list any additional services or support you need or are interested in which are not listed above.
Please indicate each of the following documents you currently HAVE access to
:
#______________
Revised 10/09/2015 4
Date: __________________
Answer which best describes you:
1. Do you know what you would like to study after high school? Yes No
a. If so what? ______________________________________
2. Do you know what school you would like to attend after high school? Yes No
a. If so where? _____________________________________
3. Do you know how to apply for college? Yes No
4. Do you know how to complete a personal statement to apply for college? Yes No
5. Do you have letters of recommendation to apply for college? Yes No
6. Have you applied to college(s)? Yes No
a. If so, how many? ______________
7. Do you know how to ride and navigate the public transit system? Yes No
8. Do you have a Banking/Savings account Yes No
9. Do you know how to create a budget? Yes No
10. Do you know how to write a resume? Yes No
11. Do you know how to be successful in an interview? Yes No
12. Check which best describes your current employment situation:
Unemployed Unpaid Internship Paid Internship Temporary/Seasonal
Part Time Full time, No benefits Full time w/ benefits
13. Do you regularly exercise and maintain well-balanced diet?
Never Rarely Sometimes Mostly Always
14. Check which best describes how often you maintain your mental and physical health
(Attend a clinic, dentist, eye exams, get medical screenings, etc.)
Never Rarely Sometimes Mostly Always
15. Do you feel you have enough community support? Yes No
Are the resources and services provided by Living Advantage, Inc. meeting your needs? Yes No
*Please let us know how your feel we can make our services more help

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