Personal Assessment

Providing safe and healthy homes for children of families in crisis.

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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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Safe Refuge for Children + Families

25A Crescent Drive, #337
Pleasant Hill, CA 94523
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Providing safe and healthy homes for children of families in crisis.

Personal Assessment

Family Background

Family and Community Support

Employment

Education History

Discipline & Behavior Management

Medical History

Safe Refuge for Children + Families

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