Life Assessment Tool - Wellington County Learning Centre

Notice with Respect to Collection of Personal Information

The information on this form is collected under the authority of the Municipal Freedom of Information and Protection of Privacy Act and the Freedom of Information and Protection of Privacy Act. This information will be used for the delivery of Wellington County Learning Centre programs and services; and the maintenance of related databases, registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to Ken Harvey, Circles Coordinator at 1.800.265.7294 x 3062.

Your Name

Food Assessment

Housing Assessment

Transportation Assessment

Please select the statement which best corresponds to your current transportation situation:

Always has transportation needs met through public transportation, a car, or a regular ride. (10) Has most transportation needs met through public transportation, a car, or a regular ride. (8) Has some transportation needs met through public transportation, a car, or a regular ride. (6) Rarely has transportation needs met through public transportation, a car, or a regular ride. (3) Does not have transportation needs met and has no available public transportation, a car or a regular ride. (0)

Support System Assessment

Please select the statement which best corresponds to your current support system:

Is able to give support as well as receive support. (10) Always has support. (9) Has a healthy support system most of the time. (8) Has a healthy support system only in times of crisis. (6) Has a healthy support system but is unreliable. (4) Has a support system but it is unhealthy and limited. (3) Does not have a support system. (0)

Mental Health Assessment

Please select the statement which best corresponds to your current mental health:

No problems in work, school, social life; superior functioning in activities that are meaningful. (10) No or minimal problems in all areas of life; some involvement in activities that are meaningful. (8) Mild to occasional problems with work, social or school settings; usually makes good choices. (6) Has great difficulty caring for self or others; significant problems with social, work, or school settings. (3) Cannot care for self or family. (1) At clear risk of harm to self or others. (0)

Rosenberg Self-Esteem Survey

Directions: Please choose the option which best matches your agreement with each statement below.

I feel that I'm a person of worth, at least on an equal par with others.