COVERED BY HEALTH INSURANCE [All Clients] No Client doesn’t know Yes Client refused HEALTH INSURANCE - HEALTH INSURANCE COVERAGE DETAILS IF “YES” TO MEDICAID (aka Medi-Cal) Obtained through COBRA MEDICARE Private Pay Health Insurance VA Medical Indian Health Services Program Employer Provided Other: (Specify) EMPLOYMENT [All Clients, For Age 16 & Over] IS CLIENT EMPLOYED No Client doesn’t know Yes Client refused If “Yes” To Employed Permanent Client Doesn’t Know Temporary Client Refused Seasonal Hours Worked Last Week: If To Employed Are You Seeking Employment? “No” – Yes Client Doesn’t Know No Client Refused EDUCATION [All Clients, For Age 5 & over] IS CLIENT CURRENTLY ENROLLED IN SCHOOL Yes Client doesn’t know No Client refused If To Enrolled Enrolled In a Vocational or Apprenticeship Program? “Yes” – Yes Client Doesn’t Know No Client Refused Highest Educational Level Completed: No School Completed 10th Grade Postsecondary School Nursery School to 4th Grade 11th Grade Client Doesn’t Know 5th or 6th Grade 12th Grade, No Diploma Client Refused 7th or 8th Grade High School Diploma 9th Grade GED Highest Degree Earned: None Doctorate Degree Degree Other Graduate/Professional Degree Associate’s Degree Certificate of advanced training or skilled artisan Bachelor’s Degree Master’s
COVERED BY HEALTH INSURANCE [All Clients] No Client doesn’t know Yes Client refused IF “YES” TO HEALTH INSURANCE - HEALTH INSURANCE COVERAGE DETAILS MEDICAID (aka Medi-Cal) Obtained through COBRA MEDICARE Private Pay Health Insurance VA Medical Indian Health Services Program Employer Provided Other: (Specify) EMPLOYMENT [All Clients, For Age 16 & Over] IS CLIENT EMPLOYED No Client doesn’t know Yes Client refused If “Yes” To Employed Permanent Client Doesn’t Know Temporary Client Refused Seasonal Hours Worked Last Week: If “No” To Employed – Are You Seeking Employment? Yes Client Doesn’t Know No Client Refused EDUCATION [All Clients, For Age 5 & over] IS CLIENT CURRENTLY ENROLLED IN SCHOOL Yes Client doesn’t know No Client refused If “Yes” To Enrolled – Enrolled In a Vocational or Apprenticeship Program? Yes Client Doesn’t Know No Client Refused Highest Educational Level Completed: No School Completed 10th Grade Postsecondary School Nursery School to 4th Grade 11th Grade Client Doesn’t Know 5th or 6th Grade 12th Grade, No Diploma Client Refused 7th or 8th Grade High School Diploma 9th Grade GED Highest Degree Earned: None Doctorate Degree Associate’s Degree Other Graduate/Professional Degree Bachelor’s Degree Certificate of advanced training or skilled artisan Master’s Degree
Adult-Assessment-Form-CoC-ESG-Programs.docx