SAFE Questionnaire I: Single Applicant

Print Name:

Date

1. Who primarily raised you? (check all that apply)

Mother and Father
Father
Mother
Mother and Stepparent
Father and Stepparent
Stepmother
Stepfather
Maternal Grandparent(s)
Paternal Grandparent(s)
Aunt(s) and/or Uncle(s)
Mother and Mother
Father and Father
Older Sibling(s)
Adoptive Parent(s)
Foster Parent(s)
Institutional Caretaker(s)
Legal Guardian(s)
Other:

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?

years of age
I currently live with my parent(s) or primary caretaker(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 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. How would you rate your parents’/primary caretakers’ ability to manage their lives?

Mother or Primary Caretaker
Father or Primary Caretaker

Mother or Primary Caretaker

Very good
Good
Fair
Poor
Unknown

Father or Primary Caretaker

Very good
Good
Fair
Poor
Unknown

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 other primary caretaker when you were a child:

13. Who primarily disciplined you during your childhood?

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

Mother or Primary Caretaker
Father or Primary Caretaker

Mother or Primary Caretaker

Mother or Primary Caretaker:

Father or Primary Caretaker

Father or Primary Caretaker:

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

Mother or Primary Caretaker
Father or Primary Caretaker

Mother or Primary Caretaker

Father or Primary Caretaker

Mother or Primary Caretaker:

Father or Primary Caretaker:

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

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

Mother or Primary Caretaker
Father or Primary Caretaker

Mother or Primary Caretaker

Father or Primary Caretaker

Mother or Primary Caretaker:

Father or Primary Caretaker:

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?

No
Yes

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

No
Yes

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?

Not applicable
Divorce
Death of spouse(s)
Annulment

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

Not applicable
Terminated partnership without legal agreement(s)
Terminated partnership with legal agreement(s)

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?

No
Yes

29. Are you currently in a relationship?

No
Yes

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. Check the boxes that best describe your current relationship with your mother and father/primary caregivers:

Mother or Primary Caretaker
Father or Primary Caretaker

Mother or Primary Caretaker

Father or Primary Caretaker

Mother or Primary Caretaker:

Father or Primary Caretaker:

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

Not applicable
All family members are helpful and supportive
Most family members are helpful and supportive
About half are helpful and supportive
Few are helpful and supportive
No family members are helpful and supportive

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?

Issues such as these do not interfere with relationships within my family
Issues such as these seldom interfere with relationships within my family
Occasionally issues such as these interfere with relationships within my family
Frequently issues such as these interfere with relationships within my family

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