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Independent Living Assessment Worksheets
Taking part in social activities is an important part of everyone’s life. Belonging
to clubs, teams or special-interest groups can help you learn and grow in many
ways. Here are some of the ways socialization can help you;
You can learn how to function in a group. It’s a chance to learn ways to solve
problems and work towards goals.
You can learn new skills and hobbies you may use the rest of your life.
You can make new friends who have the same interests as you.
You can learn leadership skills.
You can learn more about yourself and your abilities.
You’re life will be fuller if you get involved that if you let yourself
become isolated.
DISCUSS/ FOR EXAMPLE;
-You’ve moved to a new city or apartment complex, how might
getting involved in social activities help you?
-Barb is interested in learning about computers. How might social
activities help her?
-What social activities have you enjoyed that you feel have helped
you grow in some way?
c 1998 J Benshoof (revised from J. Weston Walch, Publisher c 1986)------------------------------------------------------------------------------------------------------------
Self-esteem is simply an attitude we feel about ourselves and we
choose that attitude. The pillars of self-esteem are:
Confidence grows from solid feelings of self-acceptance. Self-assured people
are content to be themselves. What we believe to be possible influences our
hopes, aspirations, actions, and the outcome of our plans. Those convinced
they have limits do not strive, while others constantly challenge their beliefs
about their limitations. Confident people act while self-doubters agonize.
Confident people welcome challenges and changes, they delight in overcoming
difficulties, and even manage to transform problems into challenges. Those who
lack confidence let their fears stand between them and their ambitions. They
resist change because it threatens their sense of security. Self-faith gives people
the power to survive serious disappointments and defeat. What makes us who
we are is our own unique way of how we perceive ourselves, the things around
us, and the world itself. Other people see a reflection of how you see yourself.
If you feel good about yourself, others will be more likely to respond to you positively.
Darrel Christenson M. S. 1998
Eliminate "self-killer" phrases.
Rid yourself of self-limiting attitudes.
Don't use negative self-suggestions.
Learn new techniques of dealing with disappointments.
Mimic the way people with high self-esteem behave.
Be persistent.
Become your own best friend.
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SELF-ESTEEM/ SELF-IMAGE
1. Write down 1 or 2 things you do well. ______________________________
2. Write down 1 or 2 things you do not do well. _________________________
3. Describe yourself in 1 or two words. _______________________________
4. Write down 1 or 2 words you think other people use to describe you. _____________________________________________________________
5. List one thing you have done in the last couple of months that made you feel
good about yourself. _____________________________________________
6. List one value you have. ________________________________________
7. What do you like about yourself? __________________________________
_____________________________________________________________
8. Look at the values listed below. Which are the most important to you?
Put number 1 - 7 before them; 1 being the most important, 7 the least.
______ Earning a lot of money
______ Helping other people
______ Raising a family
______ Having good health
______ Having a lot of friends
______ Being a religious person
______ Being proud of your life
SELF-ESTEEM BUILDERS
If you do not have good self-esteem, you can build it.
WAYS TO BUILD SELF-ESTEEM;
Display your favorite works of art, crafts, and hobbies. Pull out things you have
made, trophies you have won, and certificates you have received.
Brag a little. When you do something good, tell close family members and
friends about it.
Play your favorite records, songs. If you play music, invite friends to hear
you play. If you like to dance, go to more dances.
Put up encouraging little notes for yourself, like, "Today I will feel good
about myself", on your wall.
Look in the mirror and tell yourself good things about yourself .
Read motivational poems and readings
Do good things for yourself, and give yourself little presents. **Taking a
bubble bath or going for a walk.
Ask yourself what kind of nice things you would do for a friend, then do
them for yourself.
Hang up cards you have received from friends, or presents friends have
given you. In this way you will remind yourself that you have friends that
like you a lot because you are a nice person.
Write a list of all the good things you do and keep it in your wallet.
Dress nice.
Live each day to the fullest. Get the most from each hour, each day and
each age of your life. Then you can look forward with confidence and
back without regrets.
Be yourself, but be your best self. Dare to be different and to follow your own star.
And don’t be afraid to be happy. Enjoy what is beautiful. Love with all your
heart and soul. Believe that those you love love you.
Forget what you have done for your friends; remember what they have done
for you.
Disregard what the world owes you, and concentrate on what you owe the world.
When you are faced with a decision, make that decision as wisely as possible,
and then forget it. The moment of absolute certainty never arrives.
And, above all, remember that God helps those who helps themselves. Act as
if everything depends on you, and pray as if everything depends on God.
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MY DECLARATION OF SELF-ESTEEM: I AM ME
In the entire world there is no one exactly like me. Everything that comes out of
me is authentically mine because alone I choose it. I own everything about me--
my body, my feeling, my mouth, my voice, all my actions, whether they be to
others or to myself. I own my fantasies, my dreams, my hopes, and my fears.
I own all my triumphs and successes, all my failures and mistakes. Because I
own all of me, I can become intimately acquainted with me. By doing so, I can
love me and be friendly with me in all my parts. I know there are aspects about
myself that puzzle me, and other aspects that I do not know, but as long as I am
friendly and loving to myself, I can courageously and hopefully look for solutions
to the puzzles and for ways to find out more about me. However, I look and sound,
whatever I say and do, and whatever I think and feel at a given moment in time is
authentically me. If later, some parts of how I looked, sounded, thought, and felt turn
out to be unfitting, I can discard that which is unfitting, keep the rest, and invent
something new for that which I discard. I can see, hear, feel, think, say, and do.
I have the tools to survive, to be close to others, to be productive, and to make
sense and order out of the world of people and things outside of me. I own me,
and therefore, I can engineer me. I am me and I am okay.
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WHO ARE YOU Answer ten times below, using a noun each time to describe who you are:
1. I am ____________________________________
2. I am ____________________________________
3. I am ____________________________________
4. I am ____________________________________
5. I am ____________________________________
6. I am ____________________________________
7. I am ____________________________________
8. I am ____________________________________
9. I am ____________________________________
10. I am ___________________________________
This is all about: Helping you understand your emotional reactions to different
situations.
What you will do: 1. Complete the open-ended sentences below.
2. As a class, discuss the two questions at the bottom of the page.
Sentences to complete:
1. When I’m proud of myself, I _____________________________________
2. I love ______________________________________________________
3. I am afraid of ________________________________________________
4. I’m embarrassed when ________________________________________
5. I hate _____________________________________________________
6. I want to be _________________________________________________
7. I am happiest when ___________________________________________
8. I am worried about ___________________________________________
9. In my free time, I’d like to _______________________________________
10. Someone who means the most to me is __________________________
11. In school, I do best when ______________________________________
12. I need to work harder in ______________________________________
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Questions:
1. What did you find out about yourself?
2. What do you need to do more of to feel good about yourself?
YOU WILL RECEIVE A BODY You may like it or hate it, but it will be yours for the
entire period this time around
YOU WILL LEARN LESSONS You are enrolled in a full-time informal school
called life. Each day in this school you will have the opportunity to learn lessons.
You may like the lessons or think them irrelevant or stupid.
THERE ARE NO MISTAKES, ONLY LESSONS
Growth is a process of trial
and error: experimentation. The "failed" experiments are as much a part of the
process as the experiment that ultimately "works".
A LESSON IS REPEATED UNTIL LEARNED A lesson will be presented to you
in various forms until you have learned it. When you have learned it, you can then
go to the next lesson.
LEARNING LESSONS DOES NOT END There is no part of life that does not
contain its lesson. If you are alive, there are lessons to be learned.
"THERE " IS NO BETTER THAN "HERE" When your "there" has become a
"here" you will simply obtain another "there" that will again look better than "here"
OTHERS ARE MERELY MIRRORS OF YOU You cannot love or hate something
about another person unless it reflects to you something you love or hate in yourself.
WHAT YOU MAKE OF YOUR LIFE IS UP TO YOU You have all the tools and
resources that you need, what you do with them is up to you. The choice is yours.
YOUR ANSWERS LIE INSIDE YOU The answers to life’s questions lie inside you.
All you need to do is look, listen, and trust.
DIS-IDENTIFICATION AND SELF-IDENTIFICATION
For a moment now, turn your
attention to yourself in this room. Get in touch with your body... Get in touch with
your feelings, your mood... Get in touch with your mind, your thoughts. Now get in
touch with the observer that notices the body sensations, the feelings and thoughts.
As the observer, think of this:
"I have a body but I am not my body". My body may find itself in different conditions of
health or sickness. It may be rested or tired, but that has nothing to do with my self, my
real "I" .My body is constantly changing; it started out as a baby and grew continuously,
and will continue to change, become stronger or weaker, skilled in some new things,
and gradually grow old. I value my body as my precious instrument of experience and
of action in the outer world, but it is only an instrument. I treat it well, I try to keep it strong
and healthy, but it is not myself. I have a body, but I am not my body."
"I have emotions, but I am not my emotions. My emotions are countless, contradictory,
changing. They may swing from love to hatred, from calm to anger, from joy to sorrow,
and yet my essence-- my true nature-- has not changed. ‘I’ remain. Though a wave of
anger may try to submerge me, I know that it will pass in time; therefore, I am not this
anger. Since I can observe, and understand my emotions, and then gradually learn to
direct, use, and integrate harmoniously, it is clear that they are not my self. I have
emotions, but I am not my emotions."
"I have a mind, but I am not my mind. My mind is a valuable tool of discovery and
expression, yet it is not the essence of my being. It’s contents are constantly changing,
it gains new ideas, new knowledge and experience. It can think something falsely and
then find out the truth and think something entirely different. Sometimes it refuses to obey
me; therefore it cannot be me, myself. It is an organ of knowledge in regard to both the
outside world and my inner world, but it is not myself. I have a mind, but I am not my mind."
I have pain and pleasure but I am not my pain and pleasure. My pain and pleasure are
always changing. Sometimes the pain really hurts badly; sometimes it lets up, and
sometimes I feel really good. Sometimes my pleasure is really intense and then it lets
up and fades away. Therefore, I cannot be my pain or pleasure. I have pain and pleasure,
but I am not my pain and pleasure."
"I have thoughts, but I am not my thoughts. Sometimes my thoughts are pleasant or happy.
Sometimes they are sad or confused. My thoughts change and I watch them change. I have
thoughts, but I am not my thoughts. Sometimes my thoughts are argumentative and I let
myself have an argument. But I am not these things. These are some things that I have or
do. I see myself having or doing them. Therefore I cannot be them. I have thoughts but I
am not my thoughts."
"I have desires but I am not my desires. My desires are often changeable and contradictory,
with alternations of attraction and repulsion; therefore they are not myself. When I am hungry,
I desire food, but when I am filled I do not. I have desires, but I am not my desires."
"I have roles to play, but I am not my roles. I engage in various activities and play many
roles in life. I must play these roles, and so I willingly play them as well as possible, be it
the role of son or father, husband or student, worker or prisoner. But I am more than these
roles. These are roles, specific but partial roles, which I myself am playing, must play,
agree to play, and can watch and observe myself playing. Therefore I am not any of them.
I am self-identified, and I am not only the actor, but the director of the acting."
"Who am I then? What remains after having dis-identified myself from my body, my
sensations, my feelings, my desires, my mind and my actions?
It is the essence of my self-- a center of pure self-consciousness, of self-realization.
It is the permanent factor in the ever-varying flow of my personal life. It is that which
gives me a sense of being, of permanence, of inner balance. It is the center that
lets me know who I am, in the midst of all the flurry of external events, when I
remember myself. Take a moment right now to identify with this center, to realize
its self-consciousness, its permanence, its energy.
Now I recognize and affirm myself as the center of pure self-awareness and
creative dynamic energy. I recognize that from the center of true identity I can
learn to observe, direct, and harmonize all the psychological processes and
the physical body. I will be able to remember this experience, to remember
myself in the midst of my everyday life, and use this awareness to help me
and to give me increasing meaning and direction in my life."
2) Is there a difference?
3) Is listening important to effective communication? Why?
4) How can you let someone know that you are listening and really
'hearing' what they are saying?
1) Do you need to give advice when someone shares information about
themselves?
2) Do people always want your advice when they've shared information
about their situation?
3) Are you more 'helpful' when you give a person the answers they're
looking for, or is it better to teach them to flnd their own answers?
c: J. Benshoof 07/96
The following appeared in the classified ad section of a small-town newspaper;
On Monday-- FOR SALE: R.D. Jones has one sewing machine for sale.
Phone 958-7980 after 7 P. M. and ask for Mrs. Kelly who lives with him cheap.
On Tuesday-- NOTICE: We regret having erred in R. D. Jones’ ad yesterday.
It should have read.- One sewing machine for sale. Cheap. Phone 958-7980
and ask for Mrs. Kelly who fives with him after 7 P. M.
On Wednesday-- R. D. Jones has informed us that he has received several
annoying phone calls because of an error we made in the classified ad
yesterday. His ad stands corrected as follows: FOR SALE: R. D. Jones
has one sewing machine for sale. Cheap. Phone 958-7980 after 7 P. M.
and ask for Mrs. Kelly who loves with him.
On Thursday-- NOTICE: /, R. D. Jones, have no sewing machine for sale.
I smashed it. Don't call 958-7980 as the telephone has been taken out
I have not been carrying on with Mrs. Kelly. Until yesterday she was my
housekeeper, but she quit.
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DO
1. Describe the other person's behavior objectively.
2. Use concrete terms.
3. Describe a specified time, place, and frequency of the
disagreeable action.
4. Describe the action, not the motive.
DON’T
1. Describe your emotional reaction.
2. Use abstract, vague terms.
3. Generalize for 'all time'.
4. Guess another's motives or goals.
c: J. Benshoof 09/96
LIST OF FEELINGS THAT PERSONS HAVE
BUT OFTEN FAIL TO IDENTIFY:
ABANDONED, DESPAIR, HAPPY, NUTTY, SNEAKY,
ADEQUATE, DESTRUCTIVE, HATE, OBNOXIOUS, SOLEMN,
ADAMANT, DETERMINED, HEAVENLY, OBSESSED, SORROW,
AGONY, DIFFERENT, HELPFUL, ODD, SPITEFUL,
ALMIGHTY, DIFFIDENT, HELPLESS, OPPOSED, STARTLED
AMBIVALENT DIMINISHED HIGH OUTRAGED STINGY,
ANGRY, DISCONTENTED, HOMESICK, OVERWHELMED, STRANDED,
ANNOYED, DISTRACTED, HONORED, PAIN, STUFFED
ANXIOUS DISTRAUGHT HORRIBLE PANICKED STUPID,
APATHETIC, DISTURBED, HURT, PEACEFUL, STUNNED,
ASTOUNDED, DOMINATED, HYSTERICAL, PERSECUTED, STUPEFIED,
AWED, DIVIDED, IGNORED, PETRIFIED, SUFFERING,
BAD, DUBIOUS, IMMORTAL, PITY, SURE,
BEAUTIFUL, EAGER, IMPOSED-UPON, PLEASANT, SYMPATHETIC,
BETRAYED, ECSTATIC, IMPRESSED, PLEASED, TALKATIVE,
BITTER, ELECTRIFIED, INFATUATED, PRECARIOUS, TEMPTED,
BLISSFUL, EMPTY, INFURIATED, PRESSURED, TENACIOUS,
BOLD, ENCHANTED, INSPIRED, PRETTY, TENUOUS,
BORED, ENERGETIC, INTIMIDATED, PRIM, TENSE,
BRAVE, ENJOY, ISOLATED, PRISSY, TENTATIVE,
BURDENED, ENVIOUS, JEALOUSLY, PROUD, TERRIBLE,
CALM, EVIL, JOYOUS, QUARRELSOME, TERRIFIED,
CAPABLE, EXASPERATED, JUMPY, QUEER, THREATENED,
CAPTIVATED, FASCINATED, KIND, RAGE, TIRED,
CHALLENGED, FAUNING, KEEN, REFRESHED, THWARTED,
CHARMED, FEARFUL, LACONIC, REJECTED, TRAPPED,
CHEATED, FLUSTERED, LAZY, RELAXED, TROUBLED,
CHEERFUL, FOOLISH, LECHEROUS, RELIEVED, UGLY,
CHILDISH, FRANTIC, LEFT OUT, REMORSE, UNEASY,
CLEVER, FRUSTRATED, LICENTIOUS, RESTLESS, UNSETTLED,
COMBATIVE, FRIGHTENED, LONELY, REVERENT, VIOLENT,
COMPETITIVE, FREE, LONGING, REWARDED, VEHEMENT,
CONDEMNED, FULL, LOVING, RIGHTEOUS, VITAL,
CONFUSED, FURY, LOW, SAD, VULNERABLE,
CONSPICUOUS, GAY, LUSTFUL, SATED, VIVACIOUS,
CONTENTED, GLAD, MAD, SATISFIED, MIMCKED,
CONTRITE, GOOD, MAUDLIN, SCARED, WONDERFUL,
CRUEL, GRATIFIED, MEAN, SCREWED UP, WEEPY,
CRUSHED, GREEDY, MELANCHOLY, SERVILE, WORRY,
CULPABLE, GRIEF, MISERABLE, SETTLED, ZANY,
DECEITFUL, GROOVY, MYSTICAL, SEXY,
DEFEATED, GUILTY, NAUGHTY, SHOCKED,
DELIGHTED, GULLIBLE, NERVOUS, SILLY,
DESIROUS, HAPPY, NICE, SKEPTICAL
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-INDEPENDENT LIVING SKILLS
Check tasks that consumer is able to perform
NUTRITION/ MEAL PLANNING/ PREPARATION
_____ Plans own meals
_____ Does own grocery shopping/ puts groceries away at home
_____ Prepares own meals
_____ Sets the table
_____ Gets food to table/ eats independently
_____ Cleans up kitchen/ refrigerate leftovers/ washes dishes & puts them
away/ washes table / stove/ counter tops
COMMENTS:
________________________________________________________________
_____ Collect/ sorts dirty clothes
_____ Puts clothing/ detergent in machine/ starts washer
_____ Puts clean clothing into dryer/ starts dryer
_____ Folds/ hangs up/ puts away clean clothing
COMMENTS:
_____ Change bedding/ make bed
_____ Vacuuming/ sweeping/ mopping floors
_____ Dusting
_____ Cleaning windows/ patio doors
_____ Cleaning bathroom; toilet/ bathtub/ shower/ lavatory
_____ Cleaning kitchen ; stove & refrigerator
COMMENTS:
________________________________________________________________
BUDGETING/ FINANCIAL MANAGEMENT
_____ Understands difference between income and expense
_____ Knows current sources of income, knows amount of income
_____ Sets priorities for spending; rent/ house payment/ utilities/ food/ clothing
etc.
_____ Has a checking account
_____ Deposits own check
_____ Writes check for necessary expenses or purchases
_____ Balances own checkbook
_____ Uses ATM independently
_____ Pays necessary expenses first
COMMENTS:
________________________________________________________________
_____ Can get undressed independently
_____ Can get into tub/ shower, bathe & shampoo hair independently
_____ Can get clothing and get dressed independently
_____ Can comb hair/ shave/ apply make-up independently
COMMENTS:
________________________________________________________________
HEALTH CARE
_____ Knows the relationship between proper care and good health
_____ Knows how and who to contact for health/ first aid emergency
_____ Knows how to treat minor healthcare situations
COMMENTS
________________________________________________________________
Look at the Classified Ads and find different types or rental housing.
For each type of housing, find the ad with the least expensive place and
the ad with the most expensive place.
Least/Most
Expensive
______________________________________________________________
Rooms
_______________________________________________________________
Furnished Apartment
________________________________________________________________
Unfurnished Apartment
________________________________________________________________
Apartment to Share
________________________________________________________________
House to Share
________________________________________________________________
Condominium to Rent
________________________________________________________________
House to Rent
________________________________________________________________
Other:
________________________________________________________________
c 1988 J. Weston Walch, Publisher / Using the Newspaper to teach Basic Living Skills
_____ Understands differences in Subsidized vs. Fair Market housing
_____ Knows how to get and complete subsidized housing application
_____ In a rental situation, identifies/ understands responsibilities of/
differences in/ rights of;
_____ Tenant/ Landlord
_____ Rent
_____ Lease
_____ Eviction
_____ Deposit/ Utilities; included or extra
_____ Is able to look through and understand rental listings in newspaper and
other publications
_____ Location;
_____ Proximity to bus route
_____ Proximity to shopping
_____ Pros/Cons of having a room mate
_____ One/two bedroom
_____ Monthly rent that fits budget
_____ Lease requirements
_____ Boarding housing
_____ Share-a-home
_____ Other
COMMENTS:
_______________________________________________________________
_____ Identifies the options for public transportation; bus/ dial-a-ride /taxi
_____ Is able to read the bus book & identify which bus to take
_____ Is able to use accessible bus and related equipment
_____ Is able to get dial-a-ride/ ADA paratransit card
COMMENTS:
________________________________________________________________
HOME SAFETY/ EMERGENCY SITUATIONS
_____ Is able to respond to fire in home
_____ Call 911
_____ Use appropriate fire extinguisher
_____ Evacuate premises
_____ Respond to severe storm warning
_____ Home invasion/ break-in
_____ Toast stuck in the toaster
_____ Radio by the bathtub/ sink
_____ Sparks/ smoke coming from electric appliance
_____ Emptying ashtrays
_____ Toilet overflowing
_____ Locked self out of home
_____ Spoiled/ questionable food
_____ Abuse/ neglect by anyone; verbal or physical
COMMENTS:
________________________________________________________________
_____ Has back-up in case of no-show
_____ Organize and direct duties to make the most of time allowed
_____ Knows person/ phone number to call if problems exist
COMMENTS:
________________________________________________________________
_____ Is able to use telephone
_____ Knows number for bus information
_____ Knows number for library/ recreation
_____ Knows number for Emergencies; 911
_____ Knows name and number of apartment manager
_____ Knows number for Utility Company/ Plumber
_____ Knows number for DMV
_____ Knows number for voter information
_____ Knows number for food stamp/ financial benefit/ case manager office
_____ Telephone book
_____ Community I&R
_____ Newspaper
COMMENTS:
_______________________________________________________________
_____ Has/ knows who to contract for training/ education
_____ Answers questions regarding/ prioritizes job development
_____ Knows how/ where to look for jobs
_____ Identifies areas of interest
_____ Can develop a job search
_____ Can develop a resume
COMMENTS:
_______________________________________________________________
ON EMPLOYMENT
_____ Identifies appropriate appearance
_____ Identifies pertinent information to take
_____ Identifies appropriate questions to ask
_____ Identifies appropriate interview behaviors
_____ Identifies appropriate work behaviors
_____ Identifies appropriate employer/ employee interaction
_____ Identifies appropriate interaction with co-workers
_____ Identifies appropriate interaction with customers
COMMENTS:
______________________________________________________________
_____ Satisfied with present use of free time
_____ Would rather spend free time alone
_____ Would rather spend free time with others
_____ Would rather watch activities
_____ Would rather participate in activities
_____ Would rather participate indoors
_____ Would rather participate outdoors
_____ Would rather participate in noisy events
_____ Would rather participate in quiet events
_____ Already has enough friends/ acquaintances
_____ Has trouble making friends
_____ Has trouble keeping friends
COMMENTS:
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_____ Communicates personal information; name/ address/ phone number
_____ Communicates needs
_____ Initiates interactions
_____ Responds to verbal contact
_____ Complies with; directions from staff/ group decisions/ scheduled activities
_____ Takes responsibility for self
_____ Exhibits socially acceptable behavior
_____ General appearance
_____ Hair care
_____ Dental care
_____ Getting to location on time
_____ Medication regimes
_____ Locating items
_____ When eating with others
_____ When angry
_____ When meeting someone
_____ When in public places
_____ When receiving criticism/ correction
_____ When receiving a compliment
_____ When making a request
_____ When expressing thanks
_____ When its time to go home
COMMENTS:
________________________________________________________________
_____ Defines masturbation/ intercourse
_____ How pregnancy occurs
_____ When pregnancy occurs
_____ Signs of pregnancy
_____ Length of pregnancy
_____ Pregnancy prevention
_____ Methods of birth control/ most reliable method
_____ Defines STD’s
_____ Describes symptoms of STD’s
_____ Explains preventative measures
_____ Offers plan of action to prevent STD’s
_____ Defines AIDS/HIV
_____ Explains how AIDS/HIV is transmitted
_____ How to know if partner has AIDS/HIV
_____ Knows how AIDS/HIV is diagnosed
_____ Defines "safe sex"
_____ Understands the importance of "safe sex"
_____ Knows how people can have "safe sex"
COMMENTS:
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'RespectAbility'- OUR OWN AGENCY NEWSLETTER. (Download the Adobe .pdf reader)
(Text Only version of newsletter here)
Independent Living Specialists
North Coast Spinal Cord Injury Support Group
Independent Living Skills Workshops
'Computers for People with Disabilities' Program
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