Intake ROMA Scale Please fill out all sections and submit for signature. Basic Life Skills* NOT APPLICABLE My family has information, skills and access to others for help and support when needed and provides help and support for others (LS-10). My family generally prefers to handle problems for themselves but maintains interest and participation in activities outside the home (LS-8). My family knows when and how to ask for help outside the home and knows who to ask other than local agencies (LS-6). My family depends on various agencies' services for help and support outside the home (LS-3). My family has limited contact with others outside the home and has no one to call for help or support (LS-1). Childcare* NOT APPLICABLE Child Care is available and adequate without subsidy. (CC-8) Child Care is available and adequate with subsidy. (CC-5) Some Child Care is available but it is inadequate to meet my current needs. (CC-4) My income qualifies for a subsidy but I remain on a waitlist. (CC-3) No Child Care is available that meets my needs. (CC-1) Education* NOT APPLICABLE I have a Masters or Doctorate Degree (ED-10). I have a Bachelors Degree (ED-9). I have an Associates Degree (ED-8). I have a Vocational education or I have technical, business, or professional training (ED-7). I have been certified or have another credential (ED-6). I have a high school diploma or G.E.D. (ED-5). I have basic reading, writing, math skills but no high school diploma or G.E.D. (ED-4). English is not my first language and it is difficult for me to understand it and speak comfortably (ED-3). I did attend High School, but I'm lacking in the area of reading, writing, and basic math skills (ED-2). I did not attend high school and I have difficulty with reading, writing and basic math skills (ED-1). Health GW* NOT APPLICABLE My family is covered by private (or employer provided) health insurance. We take all needed medication as prescribed (HGW-10). My family has health insurance. We do not receive medical subsidies but sometimes must access other resources for medicine, co-pays, or other medical care which is not covered by my health insurance (HGW-8). My family receives medical assistance and/or is able to meet our medical needs most of the time (HGW-6). My family receives some medical assistance but some of my medical needs go unmet (HGW-4). My children/family have no health coverage because I cannot afford the premium (HGW-1). Income Management* NOT APPLICABLE My family pays our bills on time, puts money in savings and is on top of managing our debt each month (IM-10). My family manages our debt but we have been unable to put money into savings (IM-9). My family has begun to pay off our debt. We have some money for household spending (IM-8). My family has a poor credit record, but we have a budget for our expenses and a plan for savings (IM-7). My family can meet our basic living expenses (housing, utilities, food, clothing). We do not qualify for credit (IM-6). My family receives subsidized assistance (housing, utilities, food stamps, medicaid, Work First) and we pay most of our bills on time. We cannot get credit (IM-5). My family struggles to make car payments, cell phone payments, Cable TV, and household furnishings. We often cannot pay all our bills each month (IM-3) My family is unable to pay basic living expenses (housing, food, utilities, clothing) month-to-month (IM-1). Nutrition* NOT APPLICABLE My family is able to afford nutritious food of choice without food bank, food stamps or other subsidy assistance (N-10). My family is able to afford nutritious food most of the time without food bank, food stamps or other subsidy assistance even though our choices may be limited (N-8). My family receives Food Stamps and is able to afford nutritious food with the occasional help of a food bank and ongoing receipt of food stamps (N-6) My family is unable to afford food without the help of a food pantry, soup kitchen and the use of food stamps to meet our survival needs (N-3) My family is unable to afford food and often misses meals due to the absence of food and a food assistance subsidy (N-1) Parental Support* NOT APPLICABLE Father and Mother cooperate together to provide consistent, adequate financial and emotional support for child(ren) (PS-10). Father and Mother have consistent contact with child(ren) and provide adequate financial and emotional support most of the time (PS-8). Father and/or Mother have limited contact with child(ren) and provide limited financial and emotional support (PS-5). Father and/or Mother relies totally on the other (or another individual) to provide most of the financial and emotional support for the child(ren) (PS-3). Father and/or Mother is absent from the home, has no contact with the child(ren) and provides no financial support (PS-1). Transportation* NOT APPLICABLE I have a legal and valid Drivers License, Maintain a legal and reliable vehicle, and all my transportation needs are met. (TRNSP-10) I have access to public or private transportation for all my transportation needs. (TRNSP-8) I have access to public or private transportation for most of my transportation needs. (TRNSP-5) I have a legal and valid Drivers License and access to a vehicle or public transportation for some transportation needs. (TRNSP-4) I have access to public transportation for some transportation needs. (TRNSP-3) I have a Drivers License but no transportation is available. (TRNSP-2) I have no current Drivers License and no access to public or private transportation. (TRNSP-1) Staff Name* [wp_e_signature_sad doc=”81″]
