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  • 1. Functional Limitations and EmploymentParticipant ___________________________________________ Date _____________________ Assessed By: ______________________________________Functional Limitations-individuals’ substantial challenges to employment. Describe the limitation and document the source of information used to determine a serious limitation.Area of Limitation Serious Limitation Considerations When Assessing Circle Describe this persons limitation and Homeless People with Serious Mental Rating indicated evidence (attach relevant Illness and/or Substance Use Disorders documentation, i.e. psychiatric evaluation) A serious limitation exists if the Observe for gate (walking) problems – 1= noMobility - The physical, cognitive person requires assistance from shuffling, leaning, etc. that might reflect limitationand psychological ability to move others to get around in the cognitive impairment and interfere with 2=somefrom place to place inside and outside community; or if the individual preferred career choice. 3=moderatethe home. requires modifications, adaptive Ask about persons self-directed 4=severe technology, or accommodations transportation outside of their familiar 5= most (not typically made for other neighborhood; does candidate seem significant workers) in order to move around uncomfortable traveling outside their limitation the community; or if the person comfort zone? Does such experience needs specialized training to learn to intimidate the person’s mobility to affect move around in the community. job getting or keeping behavior? Has the person demonstrated difficulty in 1= noSelf Care - The ability to manage self A serious limitation exists if the wearing clean clothes daily? limitationor living environment (including but individual is dependent upon other Explore money management skills and 2=somenot limited to eating, toileting, individuals, services, or devices to history of meeting expenses and living 3=moderategrooming, dressing, money manage themselves or their living within budget? Any non-payment of rent? 4=severemanagement, and medication environment. Does the person realize the consequences 5= mostcompliance) as they affect the of not performing key self-care tasks on significantindividual’s ability to participate in maintaining housing? Safety? Security? limitationtraining or work-related activities.Limitations may occur because ofphysical, cognitive, or emotionalimpairments and could extend to alltasks or only to specific tasks.Self Direction - The ability to plan, A serious limitation exists if the Explore the persons ability to problem 1= noinitiate, problem solve, organize, or individual is confused or solve? Has the person had repeated limitationindependently carry out goal-directed disoriented, or requires assistance or episodes of homelessness? This can be do 2=someactivities related to self care, intervention on an ongoing basis or to dysfunction stemming from mental 3=moderatesocialization, recreation, and work. during episodes in order to perform illness or substance use. Does the person 4=severe tasks, monitor own behavior and continue to socialize not recognizing their 5= most make decisions. increased potential for relapse? significant Does the person organize themselves to limitation address weekly tasks or do they have a history of failing to get tasks done?Determination of Functional Limitations 1
  • 2. A serious limitation exists if the Does the person have a history of frequent 1= noWork Skills - The ability to perform individual is not able to obtain or job changes? limitationspecific tasks required to carry out maintain employment normally Does the person need customized services 2=somejob functions, the capacity to benefit available to persons of equivalent to perform work skills? 3=moderatefrom training in the necessary skills, age, education, training, or Lack of ability to perform occupational 4=severeand the capacity to practice the work experience. In order to acquire work tasks is a functional limitation. 5= mosthabits needed to stay employed. skills, the person requires significant modifications, adaptive technology, limitation or accommodations not typically made for other workers. A serious limitation indicates that Pay attention to the individual’s ability to 1= noWork Tolerance - Capacity to the individual will require meet the psychological demands of work limitationperform effectively and efficiently modification, adaptive technology, and their need for intervention. 2=somejobs that require various levels of or accommodations (not typically Does the person need accommodation, 3=moderatephysical and/or psychological made for other workers) in terms of such as a break to talk with job coach 4=severedemand. capacity or endurance. For example, during work shift? 5= most the individual may not be able to Can the person work 8 hrs./5days a week? significant sustain an 8-hour workday, meet If not is this inability to tolerate work limitation production standards, or perform at requirements functionally impaired? a consistent pace without frequent Can the person work at the pace of non- rest stops. disabled workers in this job class? As prescribed by the employer? Explore limitation in the person’s ability to respond to change. Is the person distracted by internal 1= noInterpersonal Skills - The A serious limitation means that an thoughts or external stimuli? limitationindividual’s ability to establish and individual has no or limited ability to Can the job seeker ask for help as needed? 2=somemaintain personal, family, and interact with others in a socially Does the person articulate work needs to 3=moderatecommunity relationships. acceptable manner or is unable to authority figures without prompting? 4=severe relate to peers or co-workers 5= most without exhibiting inappropriate significant behaviors. limitation A serious limitation exists if the If person has substance use disorder, has it 1= noCommunication - The ability to individual has severely impaired affected memory? Cognition? Test for limitationeffectively exchange information expressive or receptive these. 2=somethrough words or concepts (writing, communication, either oral or Differentiate long and short-term memory 3=moderatespeaking, listening, sign language, or written, and is not able to problems. 4=severeother adaptive methods). The communicate effectively, without Can the person listen and follow multi-step 5= mostemphasis is on limitations resulting modifications, adaptive technology, directions? significantfrom a disability-related or accommodations not typically limitationcommunication difficulty, not from a made for other workers. Upon firstcommunication problem resulting contact, the person may not befrom a language or cultural readily understood by others or maydifference. not understand others.Determination of Functional Limitations 2
  • 3. Total limitation score:________________ (The highest score is 35, reflecting the most significant limitations to employment)Indicate Employment Service Needs:A person with the most significant limitations is likely to require two or more substantial services. Substantial services are “services, which provided in the context of the counselingrelationship, collectively and significantly contribute to the achievement of an employment outcome consistent with the informed choice of the individual”. Check the services needed bythis person and indicate the reason why.  Information and Referral ____________________________________________________________________________________________________________________  Physical and/or Mental Health Treatment_______________________________________________________________________________________________________  Occupational Skills Training _________________________________________________________________________________________________________________  Supportive Services________________________________________________________________________________________________________________________  Supported Employment ___________________________________________________________________________________________________________________  Other __________________________________________________________________________________________________________________________________Determination of Functional Limitations 3