Mark C. Janesville

We transferred from our county agency and we can honestly say there is nothing out there like CCR. The attentiveness is amazing!

Both of you will complete and submit a questionnaire.

Please answer the following questions as they apply to you. Some questions may have multiple answers; please check all choices that apply.
You may add additional comments on the form. You will have an opportunity to discuss your responses during your home visits.

SAFE Questionnaire Couple

Both of you will complete and submit a questionnaire.

Please answer the following questions as they apply to you. Some questions may have multiple answers; please check all choices that apply.
You may add additional comments on the form. You will have an opportunity to discuss your responses during your home visits.

"*" indicates required fields

Name:

Date:

Pronouns:

1. Who primarily raised you?

Other

2. Were you separated from any of your parent(s)/primary caregiver(s) or significant family member(s) during your childhood for any of the following reasons?

Other

3. How old were you when you first moved away from your parent(s)/primary caregiver(s) home?

years of age

I currently live with my parent(s)/primary caregiver(s)

Years:

4. What were the circumstances that led you to leave home? Were there circumstances that led you to return?

5. Check the boxes that best characterize your childhood relationship with your parent(s)/primary caregiver(s):

a. Name:

Relationship:

Other

b. Name:

Relationship:

Other

NA

Other

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

Other

7. If you were raised by more than one parent/caregiver, check the boxes that best describe their relationship with each other when you were a child/youth:

Other

8. How would you rate your parents’/primary caregivers’ ability to manage stress in their lives?

a. Name:

Relationship:

Other

Very good

Good

Fair

Poor

Unknown

b. Name:

Relationship:

Other

Very good

Good

Fair

Poor

Unknown

9. Check the boxes that best describe the personal characteristics of your parent/primary caregiver when you were a child/youth:

a. Name:

Relationship:

Other

b. Name:

Relationship:

Other

10. Who disciplined you during your childhood?

Other

11. Check the boxes that best describe the way your parent(s)/primary caregiver(s) disciplined you during childhood:

a. Name:

Relationship

Other

b. Name:

Relationship:

Other

12. Check the boxes that represent the personal values held by your parent(s)/primary caregiver(s):

a. Name:

Relationship:

Other

b. Name:

Relationship:

Other

13. How do your own personal values compare to those of your parent(s)/primary caregiver(s)?

Basically share the same values

Share most of their values

Share some of their values

Do not share any of their values

Don’t know

14. Check boxes that best describe your parent(s)/primary caregiver(s) attitudes about sexuality when you were a child/youth:

a. Name:

Relationship:

Other

b. Name:

Relationship:

Other

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

Other

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

Other

17. When you were a child/youth, with whom would you confide?

Other

18. When you were a child or youth, did you require counseling or psychiatric care?

No

Yes

19. Are there issues, traumatic incidents, or accidents from your childhood that currently cause you distress?

No

Yes

20. Check the boxes that best describe your early dating experiences:

Other

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

Other

22. If you were married previously, how did your marriage(s) end?

Not applicable

Death of spouse(s)

Divorce

Annulment

23. If you were previously in a partnership(s), how did your partnership(s) end?

Not applicable

Death of partner(s)

Terminated partnership without legal agreement(s)

Terminated partnership with legal agreement(s)

24. If you went through a divorce or terminated a significant committed relationship, check the boxes that best describe what the experience was like for you:

Other

25. Have you ever been in a custody dispute?

No

Yes

26. How long did you know your current spouse/partner before you were married or established a partnership?

Less than 6 months

Less than a year

1 to 2 years

3 to 4 years

5 to 7 years

8 to 12 years

13 or more years

27. Check the boxes that best describe the characteristics of your current spouse/partner:

Other

28. Check the boxes that best describe the various roles you and your spouse/partner play in your relationship:

Roles YOU play in your relationship:

Other

Roles your SPOUSE/PARTNER plays in your relationship:

Other

29. How often do you and your spouse/partner argue/have conflict?

Almost daily

Once or twice a year

Rarely

Once a day

Once or twice a month

Never

Several times a day

Once or twice a week

30. Check the boxes that best describe the areas of conflict between you and your spouse/partner:

Other

31. Check the boxes that best describe the way you typically react when you have a disagreement with your spouse/partner:

Other

32. How sexually compatible are you and your spouse/partner? Sexual compatibility refers to two partners having shared similar sexual beliefs, preferences, and needs.

Very compatible

Compatible

Somewhat compatible

Not very compatible

Incompatible

33. Have you and your spouse/partner ever gone through a difficult period that threatened your relationship?

No

Yes

34. Have you and your spouse/partner ever separated?

No

Yes

35. Check the boxes that best describe your current relationship with your parent(s)/caregiver(s):

a. Name:

Relationship:

Other

b. Name:

Relationship:

Other

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

YOUR side of the family:

All family members are helpful and supportive

About half are helpful and supportive

Most family members are helpful and supportive

Few are helpful and supportive

No family members are helpful and supportive

Not applicable

Spouse/Partner’s side of the family

All family members are helpful and supportive

About half are helpful and supportive

Most family members are helpful and supportive

Few are helpful and supportive

No family members are helpful and supportive

Not applicable

37. Different viewpoints concerning such things as lifestyle, personal values, religion/spirituality, socioeconomic status, sexual orientation, race/racism, gender identity, politics, etc., can interfere with family relationships. To what degree is that the case in your immediate and extended family?

Issues such as these do not interfere with relationships within my family

Issues such as these rarely interfere with relationships within my family

Issues such as these occasionally interfere with relationships within my family

Issues such as these frequently interfere with relationships within my family

38. How comfortable are members of your extended family when it comes to being around and relating to children/youth?

YOUR side of the family:

All family members are comfortable

About half are comfortable

Most family members are comfortable

Few are comfortable

No family members are comfortable

Not applicable

SPOUSE/PARTNER’S side of the family:

All family members are comfortable

About half are comfortable

Most family members are comfortable

Few are comfortable

No family members are comfortable

Not applicable