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Personal Assessment
Each person over the Age of 18 must complete. Please answer all questions as they pertain to you. Check all the choices that apply to you.
Date
*
MM slash DD slash YYYY
Name
*
First
Last
Family Background
Who primarily raised you?
*
Mother & Father
Father
Mother
Father & Stepparent
Mother & Stepparent
Stepfather
Stepmother
Maternal Grandparent(s)
Paternal Grandparent(s)
Aunt(s) &/or Uncle(s)
Older Sibling(s)
Adoptive Parent(s)
Foster Parent(s)
Institutional Caretaker(s)
Legal Guardian(s)
Were you separated from either or both of you parents during your childhood for any of the following reasons?
*
No Separations
Parents separated
Parents Divorced
Death of Parent(s)
Abandoned by Parent(s)
Parent(s) long term hospitalization
Parent(s) in Military
Parent(s) in prison
Removed from home by police or social services
If you were separated from your parents during your childhood, please explain the circumstances.
How old were you when you when you first moved away from your parent(s) or primary caretaker(s)? What were the circumstances that led you to leave home?
*
Or are you currently living with primary caretaker(s)?
Among the children in the family you grew up in, were you the youngest, middle, youngest, or only child? (Birth Order)
*
Check ALL the boxes that best characterize your childhood relationship with your mother? If you were not primarily raised by your mother and/or father, which of the following best describes your relationship with your primary caretaker(s)?
*
No relationship
Abusive
Idolized
Neglectful
Caring & Supportive
Fun & Friendly
Warm & Gentle
Smothering
Over protective
Respectful
Affectionate
Consistent
Distant/uninvolved
Strained
Close
Took care of mother
Afraid of mother
Unpredictable
Full of conflict
Loving
Check ALL the boxes that best characterize your childhood relationship with your father? if you were not primarily raised by your mother and/or father, which of the following best describes your relationship with your primary caretaker(s)?
*
No relationship
Abusive
Idolized
Neglectful
Caring & Supportive
Fun & Friendly
Warm & Gentle
Smothering
Over protective
Respectful
Affectionate
Consistent
Distant/uninvolved
Strained
Close
Took care of father
Afraid of father
Unpredictable
Full of conflict
Loving
Check the boxes that best describe what your childhood experience was like.
*
Painful
Happy & Enjoyable
Carefree
Stable
Confusing
Frightening
Chaotic
Lonely
Sickly
Traumatic
Spoiled
Sad
Difficult to remember
Has any of the following occurred in your family of origin?
*
Domestic Violence
Drug Abuse
Physical Abuse
Alcohol Abuse
Sexual Abuse
Verbal Abuse
Divorce
Emotional Abuse
Traumatic Events
Legal Difficulties
Mental Illness
Bankruptcy
Death of Parent(s)
Medical Issues
Food Insecurity
Homelessness
Abandonment
Incarceration
None of the Above
If you have experienced a life-changing/traumatic event, please describe the details. If so, have you been able to work through it?
We work with families who have gone through hardships and trauma. We have found one of the healthiest ways to help others is to work through our own traumas/hurts first.
Are there issues, traumatic incidents, or accidents from your childhood that currently cause you distress?
*
Check the boxes that best describe your parents'/primary caretakers' relationship with each other when you were a child:
*
No relationship
Divorced
Separated
Close
Happy
Playful & Fun
Tense
Cold
Loving
Violent
Full of conflict
Domineering/Submissive
Committed
Hostile
On again/off again
Relaxed
Affected by alcohol/drug abuse
Distrustful & Suspicious
Peaceful
affected by Mental Illness
Check the boxes that best describe the personal characteristics of your mother or primary caretaker when you were a child:
*
Not Applicable
Loving
Perfectionist
Domineering
Isolated
Happy
Optimistic
Calm
Violent
Substance Abuser
Preoccupied
Self Confident
Active
Outgoing
Generous
Aggressive
Shy
Irresponsible
Pessimistic/Worrier
Temperamental
Understanding
Nervous/Anxious
Fun/Playful
Rigid
Moody
Overly Critical
Hardworking
Flexible
Content
Serious
Compassionate
Friendly/Social
Warm
Supportive
Dramatic
Irritable
Easy Going
Kind
Self-Centered
Unforgiving
Stubborn
Manipulative/Controlling
Passive
Prejudiced
Emotional
Reassuring
Forgiving
Legalistic
Check the boxes that best describe the personal characteristics of your father or primary caretaker when you were a child:
*
Not Applicable
Loving
Perfectionist
Domineering
Isolated
Happy
Optimistic
Calm
Violent
Substance Abuser
Preoccupied
Active
Outgoing
Generous
Aggressive
Shy
Irresponsible
Temperamental
Understanding
Nervous/Anxious
Fun/Playful
Rigid
Moody
Overly Critical
Hardworking
Flexible
Content
Serious
Compassionate
Friendly/Social
Supportive
Dramatic
Irritable
Easy Going
Kind
Self-Centered
Unforgiving
Manipulative/Controlling
Passive
Prejudiced
Emotional
Reassuring
Forgiving
Legalistic
Who primarily disciplined you during your childhood?
*
Check the boxes that best describe the way that your Parent(s)/Primary Caretaker(s) disciplined you:
*
Consistently
Fairly
Strictly
Leniently
Made Idle threats
Lectured
Used time outs
Reasoned with me
Spanked
Praised positive behavior
Shamed
Grounded
Removed privileges
Logical consequences
Withheld food
Ignored misbehaviors
Used physical restraints
Physically punished (other than spanking)
If necessary, please add description/clarification of the discipline you experienced as a child.
When you were a child, with whom would you confide?
*
Have you ever been in a custody dispute? If yes, please explain:
*
Check the boxes that best describe the characteristics of your current spouse:
*
Not Applicable
Religious
Uncaring
Appreciative
Affectionate
Compassionate
Dogmatic
Introvert
Emotional
Friendly
Rigid
Self-centered
Gentle
Good Listener
Playful
Distant
Thoughtful
Athletic
Workaholic
Prejudiced
Careful
Outgoing
Quick Tempered
Worrier
Dominering
Supportive
Considerate
Unhappy
Argumentative
Competitive
Sarcastic
Fault finding
Flexible
Abusive
Moody
Stubborn
Depressed
Tolerant
Communicative
Clear thinking
Anxious
Smart
Social
Unforgiving
Understanding
Romantic
Generous
Dependable
Impulsive
Good sense of humor
Kind
Forgiving
Check the boxes that best describe the various roles you play in the relationship:
*
Not Applicable
Leader
Emotional One
Initiator
Peacemaker
Comforter
Wage earner
Decision Maker
Rational one
Organizer
Compromiser
Caregiver
Follower
Negotiator
Homemaker
Check the boxes that best describe the various roles your spouse plays in the relationship:
*
Not Applicable
Leader
Emotional One
Initiator
Peacemaker
Comforter
Wage earner
Decision Maker
Rational one
Organizer
Compromiser
Caregiver
Follower
Negotiator
Homemaker
My arguments with my spouse generally involve...
*
Check the boxes that best describe the way you typically react when you have a major disagreement with your spouse:
*
Not Applicable
Reach agreement through mutual give and take
Take time to think things over before discussing
Give in and attempt to smooth things over
Seek outside help such as counselor or clergy person
Sometimes pound or break things
Change the topic
Agree to disagree
Sometimes yell and shout
Leave the house to cool off
Become silent
Try to outwit spouse
Things get physical (pushing, shoving, hitting, etc)
Do you have any other comments regarding arguments between you and your spouse?
What are some of the strength and weaknesses in your relationship?
*
Has Domestic Violence ever been a part of your relationship with your spouse?
*
Yes
No
If yes, please briefly explain
Family and Community Support
How helpful and supportive do you feel members of your household/family are/will be to you as you serve with Safe Refuge?
*
Not Applicable
All family members are helpful and supportive
Some family members are helpful and supportive
No family members are helpful supportive
How comfortable are members of your extended family when it comes to being around children?
*
Not Applicable
All family members are comfortable
Most family members are comfortable
No family members are comfortable
Check the boxes that best describe your community involvement:
*
Have no friends that I socialize with
Have a few friends that I socialize with
Have many friends that I socialize with
Regular involvement in social organizations
Occasional involvement in social organizations
Rarely get involved in social organizations
No involvement in social organizations
Active in politics
Regular attendance at religious services
Occasional attendance in religious services
Rarely/Never attend religious services
Active in community organizations
No involvement in community organizations
Employment
If you are employed outside the home, how many hours do you work in a week?
*
Not Applicable
Less than 20
20-30
31-40
41-50
More than 5
If applicable, what is the title of your job and what are your responsibilities?
*
Have you ever been fired?
*
Yes
No
If yes, please explain the circumstances surrounding your termination:
Do you plan any job or career changes in the near future?
*
Yes
No
Education History
Please check the highest level of education you have completed.
*
Less than high school
High school/GED
Some college
2 year college degree (AA, AS)
4 year college degree (BA, BS)
Master’s Degree
Professional (MD, JD)
Discipline & Behavior Management
How will you discipline a child in your care?
*
Spanking
Consistently use reasonable consequences
Physical punishment other than spanking
Have my spouse handle the discipline
Threaten punishment in the future
Lecturing
Ignore the child’s misbehavior
Tell child how angry he/she makes me
Use “time outs”
Tell child they are grounded
Make rules & consequences clear in advance
Rational discussion
Send child to their room
Take away privileges
Raise my voice
Tell child he/she should be ashamed
Discipline according to how I feel at the time
What rules are important in your family?
*
Medical History
What is the overall condition of physical health?
*
Excellent
Good
Fair
Poor
Please describe your physical health.
*
What is the overall condition of your mental health?
*
Excellent
Good
Fair
Poor
Please describe your mental health.
*
Are you currently taking any medications?
*
Yes
No
If you feel it is necessary, please describe your medical conditions.
Consent
*
I affirm that the information given in this questionnaire is correct to the best of my ability.
Please sign your name and today's date.
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