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SAFE Questionnaire - Singles Form

1. Who primarily raised you?:





2. Were you separated from either or both of your parents during your childhood for any of the following reasons?:




3. How old were you when you first moved away from your parent(s) or primary caretaker(s) home?:

5. Check the boxes that best characterize your childhood relationship with your mother or primary caregiver:






6. Check the boxes that best characterize your childhood relationship with your father or primary caregiver:






7. 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)?:






8. Check the boxes that best describe what your childhood experience was like:






9. Check the boxes that best describe your parents’/primary caretakers’ relationship with each other when you were a child:






10(a). How would you rate your mother/primary caretakers’ ability to manage their lives?:




10.(b) How would you rate your father/primary caretakers’ ability to manage their lives?:




11. Check the boxes that best describe the personal characteristics of your mother or primary caretaker when you were a child:











12. Check the boxes that best describe the personal characteristics of your father or primary caretaker when you were a child:











13. Who primarily disciplined you during your childhood?:






14.(a) Check the boxes that best describe the way your mother/primary caretaker(s) disciplined you during your childhood:










14.(b) Check the boxes that best describe the way your father/primary caretaker(s) disciplined you during your childhood:










15.(a) Check the boxes that represent the personal values held by your mother/primary caretaker(s):










15.(b) Check the boxes that represent the personal values held by your father/primary caretaker(s):










16. How do your own personal values compare to those of your parent(s)/primary caretaker(s)?:




17.(a) Check the boxes that best describe your mother/primary caretakers’ attitudes about sexuality when you were a child:







17.(b) Check the boxes that best describe your father/primary caretakers’ attitudes about sexuality when you were a child:







18. Check the boxes that best describe what you were like as a child (pre-teenage years):





19. Check the boxes that best describe what you were like as a teenager:





20. When you were a child, with whom would you confide?:






21. When you were a child or adolescent, did you require counseling or psychiatric care?:
22. Are there issues, traumatic incidents or accidents from your childhood that currently cause you distress?:
23. Check the boxes that best describe your early dating experiences:



24. Check the boxes that best describe your early sexual experiences:



25. If you were married previously, how did your marriage(s) end?:
26. If you were previously in a domestic partnership(s), how did your partnership(s) end?:


27. If you went through a divorce or terminated a domestic partnership, check the boxes that best describe what the experience was like for you:



28. Have you ever been in a custody dispute?:
29(a). Are you currently in a relationship?:
29.(b) If yes, please characterize the nature of the relationship(s):
30. How often do you argue with others?:



31. Check the boxes that best describe the major areas of conflict between you and others:





32. Check the boxes that best describe the way you typically react when you have a major disagreement with others:






33(a). Check the boxes that best describe your current relationship with your mother/primary caregivers:












33(b). Check the boxes that best describe your current relationship with your father/primary caregivers:












34. How helpful and supportive do you feel members of your extended family are/will be to you as a parent?:





35. In some families, different viewpoints concerning such things as life-style, personal values, religion, socio/economic status, sexual orientation, politics, etc., interfere with family relationships. To what degree is that the case in your family?:



36. How comfortable are members of your extended family when it comes to being around and relating to children?:





37. List your siblings according to how close or distant your relationship is with them: :




38. How many members of your immediate and extended family are ready, willing and able to fully accept an unrelated child into the family?:




39. How many people in your life, outside of your family, are ready, willing and able to provide you support as a parent?:




40. How many people in your life cause you serious conflict and stress?:




41. Check the boxes that best describe your community involvement:







42. If you are employed outside of the home, how many hours per week do you work?:



43. If you are employed outside of the home, how long have you worked at your current job?:

44. Whether you work inside or outside the home, do you enjoy your work?:
45. Have you ever been fired?:
46. Do you plan any career or job changes in the near future?:
47. How do/will you discipline a child in your care?:









48. What is the overall condition of your health?:
49. Have you ever been hospitalized or had surgery?:
50. Are you currently taking any medication(s)?:
51. Have you or any of the family members listed below had any of the following conditions? Indicate which family member by using the following code, placing the appropriate number in front of the condition. 1 = SELF
2 = PARENT(S)
3 = SIBLING(S)
4 = CHILDREN
Diabetes:
Arthritis:
Seizures:
High blood pressure:
Cancer:
Frequent headaches:
Kidney disease:
High cholesterol:
Asthma:
Hearing loss:
Impaired sight:
Allergies:
Ulcers:
Insomnia:
Sickle cell anemia:
Heart condition:
Colitis:
Tuberculosis:
Thyroid condition:
Intellectual disability:
Alcoholism:
Drug addiction:
Developmental disability:
Anxiety/Panic attacks:
Depression:
Bipolar illness:
Attention deficit disorder:
Infertility/Sterility:
Schizophrenia:
Eating disorder:
Sexually transmitted desease: