Department of Assistive and Rehabilitative Services Supported Employment Assessment  




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Department of Assistive and Rehabilitative Services

Supported Employment Assessment  

General Instructions  

DARS1612, Supported Employment Assessment (SEA), is a detailed document that describes the consumer’s interests, preferences, and support needs and provides insight into the interventions that may lead to a successful job match and retention. The SEA should provide the information needed to develop the DARS1613, Supported Employment Services Plan—Part 1, which defines a plan of action for successful placement, or the DARS1800, Supported Self-Employment Services Plan, which defines the actions for planning and establishing a small business. The supported employment specialist (SES) should use this form as a guide and worksheet to direct the discovery process and gather information throughout the assessment. The SEA is designed to facilitate the use of the person-centered approach, which is required, and the SES should complete the assessment components in the order that they appear on the form: A. Consumer Discovery Interview, B. Interview with Circle of Support Members, and C. Informational Interviews or Work Skills Observations.        

Complete the form electronically and follow the procedure below.  



  • Record an answer to each question as it relates to the services provided.

  • For descriptive questions, write narrative summaries in paragraph form in clear English.  

  • Base this report primarily on direct observations of the consumer in multiple settings and environments unless the section indicates information to be collected from others.  

  • Review the form carefully and leave no blanks. Answer all questions. If a question or section does not apply, enter “Not Applicable” (N/A) and explain why.

  • Make certain that all standards have been met before submitting this form with an invoice for payment.

Note: The provider collects the information and completes this form except the sections indicated for “DARS Use Only.”  

Service Information  

Service authorization (SA) numbers:      

Discovery process: Discovery dates must be within the SA start and end dates.  

Date Discovery was initiated

Enter date of first meeting with the consumer:

     


Date Discovery was finished

Enter date of last meeting with the consumer:

     


Consumer Identification Information  

Last name:      

First name:      

Middle name:      

Street address: (include apartment and room number, if applicable)

     


City:      

State:   

ZIP code:      

Primary contact number: (   )      

Secondary contact number: (   )      

DARS case ID:      

Email address:      

Does the consumer have a legal representative?    Yes    No

If yes, enter name of the person:      

Alternate Contact Person’s Information  

Alternate contact person’s name:

     


Alternate contact person’s email address:

     


Alternate’s primary phone number:

(   )      



Alternate’s secondary phone number:

(   )      



A. Consumer Discovery Interview  

The Consumer Discovery Interview should be completed first and should be conducted only with the consumer. To gather the information through Discovery, take the consumer to local shopping malls, music stores, parks, or other venues that they visit. The goal is to stimulate participation that will help you learn about the consumer’s interests from the consumer’s perspective rather than from the perspective of a caregiver or a professional social services employee. If the consumer cannot give answers to the questions in this section, the provider will need to gain the information through observations of the consumer participating in Discovery activities.      

Describe your typical weekday. (For example, what time you get up, what you do to stay busy, when you perform routine tasks, and when you go to bed)

     


Describe your typical weekend. (For example, what time you get up, what you do to stay busy, when you perform routine tasks, and when you go to bed)

     


Who are the people in your life? (family, friends, roommates, attendant, teachers, and professionals)

     


List at least three places where you spend time. (For example, church, home, and school)  

  1.      

  1.      

  1.      

List five tasks or activities you like.  

1.      

2.      

3.      

4.      

5.      




List five tasks or activities you dislike.  

1.      

2.      

3.      

4.      

5.      




List your strengths, skills, and talents.  

1.      

2.      

3.      

4.      

5.      




List your challenges.  

1.      

2.      

3.      

4.      

5.      




What are your fears, worries, or nightmares?

     


What things do you want to avoid?

     


What choices and things do you have control of in your life?

     


What choices and things are controlled by others in your life?

     


What are your current dreams and goals related to life and work?

     


Describe your long-term dreams and goals related to life and work.

     


How do you plan to meet your needs, dreams, desires, and goals?

     


Describe all accommodations or assistance you may need for living and working in the community.

     


Are there times during the day or week that you are interested in “protecting” or “saving” because of other commitments or supports needs that cannot be met? The provider should enter these as Employment Conditions on the Employment Plan as appropriate.

     


How important to you is social contact with others?

     


Are there barriers that interfere with your ability to socialize with others?

     


Are you able to meet your basic needs such as food, housing, transportation, medical, and personal support needs?

     


What motivators and coping strategies have worked successfully for you in the past?

     


Self-analysis:

Ask the following questions of the consumer and of his or her supports. Indicate who provided the responses (for example, the consumer, the parent)  



Are you self-motivated?      

Do you have a positive outlook?      

Do you enjoy making your own decisions?      

Are you competitive by nature?      

Do you practice self-control?      

Do you plan ahead?      

Do you get tasks done on time?      

Do you have high amounts of physical stamina and emotional energy?      

Do you enjoy a changing environment and pace of work?      

Can you work many hours every week?      

Do you get along with different kinds of people?      

Summary of Consumer Discovery Interviews:

Answer the following questions to assist in summarizing the results of your interview with the consumer.  

What were the consumer’s communication needs during discovery interviews?

     


What supports and accommodations were provided to facilitate the discovery interviews with the consumer?

     


What activities and environments were used to facilitate communication and trust with the consumer?

     


Where were the interviews completed?

     


What were your overall impressions?

     


Additional comments:

     


B. Interviews with Circle of Support Members  

The interviews with Circle of Support members must be completed after the Consumer Discovery Interview to verify the information provided by the consumer and to gather additional detail needed to begin identifying options for employment.     The Circle of Support includes family (parent or guardian, spouse, children, siblings), friends, and other people in the community that are available to support the consumer with employment.

Record Circle of Support information below.

Name:      

Relationship:      

Support that can be provided:

     


Name:      

Relationship:      

Support that can be provided:

     


Name:      

Relationship:      

Support that can be provided:

     


Name:      

Relationship:      

Support that can be provided:

     


Residential History and Domestic Information  

Gather the information in this section through interviews with the Circle of Support Members  

Current living situation:

Describe the consumer’s current living situation. How long has the consumer lived at the current location? Does the consumer plan to remain at this location when he or she gets a job? Is anything potentially putting this living arrangement at risk?

     


Home Management Skills:

Get reports from Circle of Support members about the consumer’s ability to perform chores in the home and verify the reports through observations of the consumer performing the chores, as appropriate, to identify possible transferable work skills. Observe and document performance and be sure to document all safety issues identified.  

Chores  

Independent

Prompting

Physical assistance

Wash dishes  

  

  

  

Cleaning  

  

  

  

Feed and groom pets  

  

  

  

Laundry  

  

  

  

Meal preparation  

  

  

  

Mop and sweep  

  

  

  

Organize bedroom  

  

  

  

Vacuum  

  

  

  

Other: Describe      

  

  

  




Describe the consumer’s ability and willingness to perform such routine and non-routine activities in his or her current living situation as cleaning, laundry, cooking, and personal hygiene. Does the consumer enjoy some activities more than others?

     


Financial status:

Describe the consumer’s current financial status. Does the consumer have a source of income other than Social Security benefits?

     


How much does the consumer need to earn per week or per month to meet his or her obligations?

     


Benefit Status:

Be sure to refer to benefits planning information provided by the counselor.  

Does the consumer receive Social Security Disability (SSDI) on his or her own record, Social Security Childhood Disability Benefits (CDB) and/or Social Security Disabled Widow/Widower Benefits?

   Yes    No

Amount:

     


Does the consumer receive another type of Social Security cash benefit (retirement or other survivor benefits)?

   Yes    No

Are the Social Security benefits received under a parent’s Social Security number?

   Yes    No

Does the consumer receive Social Security Income (SSI)?

   Yes    No

Does the consumer receive any of the following?

Medicare

   Yes    No

Public assistance

   Yes    No

Medicaid

   Yes    No

Other disability-related Income

   Yes    No

SNAP

   Yes    No

Ticket to Work

   Yes    No

Additional Comments:

     


Children and child care issues:  

Does the consumer have children living at home?    Yes    No

Does consumer have available and stable childcare?    Yes    No

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