FOR OFFICIAL USE ONLY | ADHOC COMMITTEE

RUBRIC FORM | Hierarchy of Needs

First name of potential beneficiary

Last name

Date of Assessment

Case Number

SELF-ACTUALIZATION > FULFILLMENT > Creative Expression > Full Potential

Score (Max 10)

SELF-ESTEEM > PSYCHOLOGICAL NEEDS > Self-Value | Confidence | Respect | Self-Worth

Score (Max 10)

LOVE & BELONGINGNESS > PSYCHOLOGICAL NEEDS > Connection | Love | Relationships

Score (Max 10)

SAFETY > BASIC NEEDS > Health | Family | Resources | Property

Score (Max 40)

Score (Max 30)

TOTAL SCORE (__/100)

Evaluators

Other significant information

Any current fundraising or source funding ongoing for or in behalf of the potential beneficiary?

KEEP INFORMATION CONFIDENTIAL | Destroy all notes used to gather information after data is entered on this portal.