SayPro Client Needs Survey Template: A structured form or digital survey that gathers essential information

SayPro Client Needs Survey Template

The SayPro Client Needs Survey is designed to gather comprehensive information about the clients’ needs across various areas such as healthcare, employment, education, housing, and other services. The survey aims to understand clients’ current circumstances and future goals to tailor personalized support programs and services effectively. Below is a detailed breakdown of the survey template, which can be customized and used digitally or on paper.

SayPro Client Needs Survey

Client Information

-Full Name: ____________________________
-Date of Birth: ____________________________
-Gender: [ ] Male [ ] Female [ ] Non-Binary [ ] Prefer not to say
-Contact Information:
– Phone Number: _______________________
– Email Address: _______________________
– Mailing Address: _______________________
– Preferred method of contact: [ ] Phone [ ] Email [ ] In-person
-Emergency Contact Information:
– Name: _______________________________
– Relationship: _______________________
– Phone Number: _______________________

1. Healthcare Needs

-Do you currently have health insurance? [ ] Yes [ ] No
-If yes, what type of health insurance do you have? [ ] Private [ ] Public (Medicaid, Medicare, etc.) [ ] Other: ___________
-Do you have any chronic health conditions? [ ] Yes [ ] No
If yes, please list: _______________________________________________________
-Do you have a primary care doctor? [ ] Yes [ ] No
If yes, please provide their name and contact information:
_____________________________________________________________________
-Do you need assistance with accessing healthcare services? [ ] Yes [ ] No
If yes, what services do you need assistance with?
[ ] Doctor’s appointments [ ] Prescription medication [ ] Mental health services [ ] Other: ___________
-Do you need information or assistance regarding public health programs (e.g., vaccination, screening programs)? [ ] Yes [ ] No

2. Employment and Career Development

-Are you currently employed? [ ] Yes [ ] No
If yes, what is your occupation? ___________________________________________
-What type of employment are you seeking?
[ ] Full-time [ ] Part-time [ ] Temporary [ ] Freelance/Contract [ ] Not looking for work at this time
If you are seeking employment, what kind of work are you looking for?
______________________________________________________________________
-Do you need assistance with resume building, interview preparation, or job search? [ ] Yes [ ] No
-Have you ever received job training or educational certifications? [ ] Yes [ ] No
If yes, please list them: ____________________________________________________
-Would you like to receive assistance with career counseling or job readiness programs? [ ] Yes [ ] No
-Do you have any barriers to employment (e.g., transportation, childcare, criminal record, lack of experience)? [ ] Yes [ ] No
If yes, please explain: ___________________________________________________

3. Educational Needs and Support

-Are you currently enrolled in any educational programs? [ ] Yes [ ] No
If yes, what level of education are you pursuing?
[ ] High School [ ] Vocational Training [ ] College [ ] Graduate School
Name of institution: _________________________________________
-What type of educational support do you need?
[ ] Tutoring [ ] Test preparation [ ] Career counseling [ ] Financial aid information [ ] Other: _______________
-Do you need assistance with obtaining your high school diploma or GED? [ ] Yes [ ] No
-Would you like to pursue any vocational or technical certifications? [ ] Yes [ ] No
If yes, please specify: ______________________________________________
-Are there any barriers preventing you from pursuing your educational goals? [ ] Yes [ ] No
If yes, please explain: ___________________________________________________

4. Housing and Living Situation

-What is your current housing situation?
[ ] Own a home [ ] Rent [ ] Living with family/friends [ ] Homeless or at risk of homelessness
-Are you looking for housing assistance or support? [ ] Yes [ ] No
If yes, what type of assistance do you need?
[ ] Housing voucher [ ] Rent assistance [ ] Emergency housing [ ] Homeownership support [ ] Other: ___________
-Do you need assistance with finding affordable housing? [ ] Yes [ ] No
-Do you have any issues with your current living situation? [ ] Yes [ ] No
If yes, please describe: _________________________________________________
-Would you be interested in receiving financial literacy or budgeting assistance? [ ] Yes [ ] No

5. Financial Needs and Support

-Do you currently have a source of income? [ ] Yes [ ] No
If yes, what is your source of income? _____________________________________
-Are you seeking assistance with financial support (e.g., public assistance, food programs)? [ ] Yes [ ] No
-Do you have any existing debts or financial obligations that are a burden? [ ] Yes [ ] No
If yes, please describe: ________________________________________________
-Would you like assistance with debt management or budgeting? [ ] Yes [ ] No

6. Legal and Advocacy Needs

-Do you need assistance with any legal issues? [ ] Yes [ ] No
If yes, please specify the nature of the legal issue:
[ ] Housing eviction [ ] Family law [ ] Criminal record expungement [ ] Immigration issues [ ] Other: ________________
-Do you need information or assistance with accessing legal advocacy or representation? [ ] Yes [ ] No
-Have you experienced discrimination or mistreatment in any area (e.g., housing, employment, education)? [ ] Yes [ ] No
If yes, please describe: ________________________________________________

7. Personal Support and Social Needs

-Do you have a support network (family, friends, community)? [ ] Yes [ ] No
If yes, please describe: _________________________________________________
-Do you need any social support services (e.g., childcare, transportation, food security)? [ ] Yes [ ] No
If yes, what services do you need?
[ ] Childcare [ ] Transportation [ ] Food assistance [ ] Social interaction or companionship [ ] Other: ___________
-Are you involved in any community or social organizations? [ ] Yes [ ] No
If yes, please provide details: _________________________________________

8. Mental Health and Wellness

-Do you have any mental health needs or concerns? [ ] Yes [ ] No
If yes, please explain: __________________________________________________
-Are you currently receiving mental health services or counseling? [ ] Yes [ ] No
If yes, who is providing these services?
________________________________________________________
-Would you like information or assistance with mental health services? [ ] Yes [ ] No
-Do you feel safe in your current living or social environment? [ ] Yes [ ] No
If no, please explain: _________________________________________________

9. Additional Information

-Is there anything else you would like to share about your needs or circumstances?
_____________________________________________________________

Survey Completion and Consent

-I consent to providing the information contained in this survey for the purpose of receiving support services. I understand that all information will be kept confidential.
[ ] Yes [ ] No
Client Signature: ______________________
Date: _______________________

Thank you for completing this survey. Your responses will help us tailor services to better meet your needs and provide the support you require. If you have any questions or need assistance, please contact our office at [Insert contact information].

This survey should be kept confidential and used only to assess and provide support for clients in a way that aligns with their needs. It can be adjusted as needed based on the specific services SayPro provides and can also be formatted for online submission.