1. Functional Limitations and Employment
Participant ___________________________________________ 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= no
Mobility - The physical, cognitive person requires assistance from shuffling, leaning, etc. that might reflect limitation
and psychological ability to move others to get around in the cognitive impairment and interfere with 2=some
from place to place inside and outside community; or if the individual preferred career choice. 3=moderate
the 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= no
Self Care - The ability to manage self A serious limitation exists if the wearing clean clothes daily? limitation
or living environment (including but individual is dependent upon other Explore money management skills and 2=some
not limited to eating, toileting, individuals, services, or devices to history of meeting expenses and living 3=moderate
grooming, dressing, money manage themselves or their living within budget? Any non-payment of rent? 4=severe
management, and medication environment. Does the person realize the consequences 5= most
compliance) as they affect the of not performing key self-care tasks on significant
individual’s ability to participate in maintaining housing? Safety? Security? limitation
training or work-related activities.
Limitations may occur because of
physical, cognitive, or emotional
impairments and could extend to all
tasks or only to specific tasks.
Self Direction - The ability to plan, A serious limitation exists if the Explore the persons ability to problem 1= no
initiate, problem solve, organize, or individual is confused or solve? Has the person had repeated limitation
independently carry out goal-directed disoriented, or requires assistance or episodes of homelessness? This can be do 2=some
activities related to self care, intervention on an ongoing basis or to dysfunction stemming from mental 3=moderate
socialization, 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= no
Work Skills - The ability to perform individual is not able to obtain or job changes? limitation
specific tasks required to carry out maintain employment normally Does the person need customized services 2=some
job functions, the capacity to benefit available to persons of equivalent to perform work skills? 3=moderate
from training in the necessary skills, age, education, training, or Lack of ability to perform occupational 4=severe
and the capacity to practice the work experience. In order to acquire work tasks is a functional limitation. 5= most
habits 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= no
Work Tolerance - Capacity to the individual will require meet the psychological demands of work limitation
perform effectively and efficiently modification, adaptive technology, and their need for intervention. 2=some
jobs that require various levels of or accommodations (not typically Does the person need accommodation, 3=moderate
physical and/or psychological made for other workers) in terms of such as a break to talk with job coach 4=severe
demand. 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= no
Interpersonal Skills - The A serious limitation means that an thoughts or external stimuli? limitation
individual’s ability to establish and individual has no or limited ability to Can the job seeker ask for help as needed? 2=some
maintain personal, family, and interact with others in a socially Does the person articulate work needs to 3=moderate
community 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= no
Communication - The ability to individual has severely impaired affected memory? Cognition? Test for limitation
effectively exchange information expressive or receptive these. 2=some
through words or concepts (writing, communication, either oral or Differentiate long and short-term memory 3=moderate
speaking, listening, sign language, or written, and is not able to problems. 4=severe
other adaptive methods). The communicate effectively, without Can the person listen and follow multi-step 5= most
emphasis is on limitations resulting modifications, adaptive technology, directions? significant
from a disability-related or accommodations not typically limitation
communication difficulty, not from a made for other workers. Upon first
communication problem resulting contact, the person may not be
from a language or cultural readily understood by others or may
difference. 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 counseling
relationship, collectively and significantly contribute to the achievement of an employment outcome consistent with the informed choice of the individual”. Check the services needed by
this 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