Client Reentry Assessment Form
Evaluate the readiness of returning clients to reengage with services using this comprehensive assessment form.
Client Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How ready do you feel to reengage with our services?
*
1
2
3
4
5
Please indicate your agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am motivated to participate in services.
1
2
3
4
5
I have the support I need to succeed.
6
7
8
9
10
I understand the expectations for reentry.
11
12
13
14
15
I feel confident about my ability to benefit from services.
16
17
18
19
20
What are your primary goals for reengagement?
Which of the following may present barriers to your reentry?
Transportation
Childcare
Work Schedule
Health Concerns
Other
How would you rate your current support system?
Very Weak
1
2
3
4
Very Strong
5
1 is Very Weak, 5 is Very Strong
Have there been any significant changes in your circumstances since your last engagement?
Yes
No
If yes, please describe the changes.
Additional comments or feedback
Submit Assessment
Should be Empty: