SAFE Questionnaire Single Fill Form

Print Name:
Date
Date Format: MM slash DD slash YYYY
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?
- 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 your home by police or social services
- Other:
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:
- No relationship
- Abusive
- Idolized
- Neglectful
- Caring
- Supportive
- Fun
- Friendly
- Warm
- Gentle
- Smothering
- Demonstrative
- Over protective
- Respectful
- Affectionate
- Anxious
- Consistent
- Distant/Uninvolved
- Superficial
- Strained
- Close
- Took care of mother
- Afraid of mother
- Unpredictable
- Full of conflict
- Relaxed
- Loving
- Other:
6. Check the boxes that best characterize your childhood relationship with your father or primary caregiver:
- No relationship
- Abusive
- Idolized
- Neglectful
- Caring
- Supportive
- Fun
- Friendly
- Warm
- Gentle
- Smothering
- Demonstrative
- Over protective
- Respectful
- Affectionate
- Anxious
- Consistent
- Distant/Uninvolved
- Superficial
- Strained
- Close
- Took care of mother
- Afraid of mother
- Unpredictable
- Full of conflict
- Relaxed
- Loving
- Other:
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)?
- No relationship
- Abusive
- Idolized
- Neglectful
- Caring
- Supportive
- Fun
- Friendly
- Warm
- Gentle
- Smothering
- Demonstrative
- Over protective
- Respectful
- Affectionate
- Anxious
- Consistent
- Distant/Uninvolved
- Superficial
- Strained
- Close
- Took care of mother
- Afraid of mother
- Unpredictable
- Full of conflict
- Relaxed
- Loving
- Other:
8. Check the boxes that best describe what your childhood experience was like:
- Painful
- Happy
- Fun
- Wonderful
- Exciting
- Unhappy
- Carefree
- Stable
- Confusing
- Frightening
- Chaotic
- Lonely
- Secure
- Sickly
- Traumatic
- Spoiled
- Enjoyable
- Sad
- Stimulating
- Difficult to remember
- Other:
9. 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
- Fun and playful
- Distrustful and suspicious
- Cold
- Loving
- Violent
- Fulfilling
- Full of conflict
- Domineering/Submissive
- Tense
- Committed
- Hostile
- On again/Off again
- Supportive
- Relaxed
- Affected by alcohol/drug abuse
- Other:
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:
- 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
- Irrational
- Manipulative/Controlling
- Passive
- Prejudiced
- Emotional
- Reassuring
- Other:
12. Check the boxes that best describe the personal characteristics of your father or other 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
- Irrational
- Manipulative/Controlling
- Passive
- Prejudiced
- Emotional
- Reassuring
- Other:
13. Who primarily disciplined you during your childhood?
- Both parents equally
- Mother
- Father
- Stepmother
- Stepfather
- Older sibling(s)
- Other:
- Maternal grandparent(s)
- Paternal grandparent(s)
- Aunt and/or uncle
- Foster parent(s)
- Legal guardian(s)
- Primary caretaker(s)
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
- Not applicable
- Consistently
- Fairly
- Strictly
- Leniently
- Made idle threats
- Lectured
- Used time outs
- Reasoned with me
- Spanked
- Family Meetings
- Other:
- Praised positive behaviors
- Shamed
- Grounded
- Removed privileges
- Logical consequences
- Withheld food
- Sent me to my room
- Ignored misbehaviors
- Used physical restraints
- Physically punished(other than spanking)
Father or Primary Caretaker
- Not applicable
- Consistently
- Fairly
- Strictly
- Leniently
- Made idle threats
- Lectured
- Used time outs
- Reasoned with me
- Spanked
- Family Meetings
- Other:
- Praised positive behaviors
- Shamed
- Grounded
- Removed privileges
- Logical consequences
- Withheld food
- Sent me to my room
- Ignored misbehaviors
- Used physical restraints
- Physically punished(other than spanking)
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
- Not applicable
- Religious beliefs
- Compassion
- Social conscience
- Strong work ethic
- Being responsible
- Freedom of expression
- Leading a balanced life
- Being a parent
- Patriotism
- Spiritual/Cultural Practice
- Honesty
- Family closeness
- Family support
- Social status
- Education
- Self respect
- Independence
- Making money
- Fidelity
- Healthy life style
- Other:
Father or Primary Caretaker
- Not applicable
- Religious beliefs
- Compassion
- Social conscience
- Strong work ethic
- Being responsible
- Freedom of expression
- Leading a balanced life
- Being a parent
- Patriotism
- Spiritual/Cultural Practice
- Honesty
- Family closeness
- Family support
- Social status
- Education
- Self respect
- Independence
- Making money
- Fidelity
- Healthy life style
- Other:
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
- Unknown
- Open about sexuality
- Comfortable discussing
- Old fashioned
- Never discussed sex
- No sex before marriage
- Condemned homosexuality
- Knowledgeable
- Awkward discussing
- Believed sex was sinful
- Liberal sexual attitudes
- Conservative attitudes
- Sexually repressed
- Sexually irresponsible
- Supported sex education
- Other:
Father or Primary Caretaker
- Unknown
- Open about sexuality
- Comfortable discussing
- Old fashioned
- Never discussed sex
- No sex before marriage
- Condemned homosexuality
- Knowledgeable
- Awkward discussing
- Believed sex was sinful
- Liberal sexual attitudes
- Conservative attitudes
- Sexually repressed
- Sexually irresponsible
- Supported sex education
- Other:
18. Check the boxes that best describe what you were like as a child (pre-teenage years):
- Happy
- Temperamental
- Stubborn
- Unhappy
- Aggressive
- Fearful
- Awkward
- Self-confident
- Friendly
- Calm
- Serious
- Hyperactive
- Responsible
- Sad
- Irresponsible
- Anxious/Nervous
- Active
- Funny
- Rebellious
- Disobedient
- Outgoing
- Sickly
- Insecure
- Obedient
- Shy
- Curious
- Compliant
- Thoughtful
- Quiet
- Other:
19. Check the boxes that best describe what you were like as a teenager:
- Happy
- Temperamental
- Stubborn
- Unhappy
- Aggressive
- Fearful
- Awkward
- Self-confident
- Friendly
- Calm
- Serious
- Hyperactive
- Responsible
- Sad
- Irresponsible
- Anxious/Nervous
- Active
- Funny
- Rebellious
- Disobedient
- Outgoing
- Sickly
- Insecure
- Obedient
- Shy
- Curious
- Compliant
- Thoughtful
- Quiet
- Other:
20. When you were a child, with whom would you confide?
- Mother
- Father
- Sibling(s)
- Grandparent(s)
- Aunt(s)/Uncle(s)
- Stepparent
- Primary Caretaker(s)
- Cousin(s)
- Counselor(s)/Teacher(s)
- Psychiatrist(s)/Psychologist(s)/Social Worker(s)
- Clergy
- Friends
- No One
- Other:
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:
- Didn’t date
- Fun
- Unremarkable
- Chaperoned
- Traumatic
- Too much too soon
- Dull
- In groups
- Extensive
- Unusual
- Pressured
- Friendly
- Frightening
- Exciting
- Limited
- Other:
24. Check the boxes that best describe your early sexual experiences:
- Limited
- Traumatic
- Awkward
- Exciting
- Unremarkable
- Unusual
- Romantic
- Regretful
- Frightening
- Confusing
- Shameful
- Amusing
- Pleasurable
- Abusive
- Pressured
- Other:
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:
- Not applicable
- Easy
- Expensive
- Painful
- Unfair
- Bitter
- Amicable
- Crazy
- Frustrating
- Fair
- Devastating
- A relief
- Long and drawn out
- Depressing
- Other:
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):
- Long term
- New
- Intimate
- Casual
- Multiple Relationships
30. How often do you argue with others?
- Never
- Rarely
- Once or twice a week
- Once or twice a year
- Once or twice a month
- Several times a day
- Almost daily
- Once a day
31. Check the boxes that best describe the major areas of conflict between you and others:
- Not applicable
- Discipline of children
- Religion
- Alcohol/Drugs
- Emotional closeness
- Family involvement
- Personal habits
- Household chores
- Work
- Infidelity
- Emotional separateness
- Money
- Sexual relations
- Politics
- Values
- Separate activities
- Time apart
- Travel
- Personal expectations
- Friends
- Leisure time
- Shared activities
- Time together
- Other:
32. Check the boxes that best describe the way you typically react when you have a major disagreement with others:
- 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 a counselor/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 them
- Things get physical (pushing, shoving, hitting)
- Other:
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
- Mother deceased
- No contact
- Strained
- Distant
- Caring
- Emotionally intense
- Flexible
- Hostile
- Understanding
- Argumentative
- Manipulative
- Positive
- Supportive
- Dependent
- Loving
- Very close
- Comfortable
- Over involved
- Not involved enough
- On again/off again
- Problematic
- Enjoyable
- Improving
- Gratifying
- I am caretaker for
- Other:
Father or Primary Caretaker
- Mother deceased
- No contact
- Strained
- Distant
- Caring
- Emotionally intense
- Flexible
- Hostile
- Understanding
- Argumentative
- Manipulative
- Positive
- Supportive
- Dependent
- Loving
- Very close
- Comfortable
- Over involved
- Not involved enough
- On again/off again
- Problematic
- Enjoyable
- Improving
- Gratifying
- I am caretaker for
- Other:
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?
- Not applicable
- All family members are comfortable
- Most family members are comfortable
- About half are comfortable
- Few are comfortable
- No family members are comfortable
37. List your siblings according to how close or distant your relationship is with them:
- I don’t have any brothers or sisters
37. List your siblings according to how close or distant your relationship is with them:
- I am very close to:
37. List your siblings according to how close or distant your relationship is with them:
- I am somewhat close to:
37. List your siblings according to how close or distant your relationship is with them:
- I am distant from:
37. List your siblings according to how close or distant your relationship is with them:
- I am in conflict with:
38. How many members of your immediate and extended family are ready, willing and able to fully accept an unrelated child into the family?
- All family members are ready, willing and able to fully accept
- Most family members are ready, willing and able to fully accept
- About half are ready, willing and able to fully accept
- Few are ready, willing and able to fully accept
- No family member is ready, willing and able to fully accept
39. How many people in your life, outside of your family, are ready, willing and able to provide you support as a parent?
- There are numerous people who are ready, willing and able to be supportive
- There are several people who are ready, willing and able to be supportive
- There are a few select people who are ready, willing and able to be supportive
- There is one person who is ready, willing and able to be supportive
- There is nobody who is ready, willing and able to be supportive
40. How many people in your life cause you serious conflict and stress?
- There are numerous people who cause me serious conflict and stress
- There are several people who cause me serious conflict and stress
- There are a few select people who cause me serious conflict and stress
- There is one person who causes me serious conflict and stress
- There is nobody who causes me serious conflict and stress
41. 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 community organizations
- Other:
- Active in politics
- Regular attendance at religious services
- Occasional attendance at religious services
- Rarely/Never attend religious services
- Active in community organizations
- Occasional involvement in community organizations
- Cultural events
42. If you are employed outside of the home, how many hours per week do you work?
- Not applicable
- Less than 20 hours
- 20 - 30 hours
- 31 - 40 hours
- 41- 50 hours
- More than 50 hours
43. If you are employed outside of the home, how long have you worked at your current job?
- Not applicable
- How many years and months
Years:
Months:
44. Whether you work inside or outside the home, do you enjoy your work?
- No
- Most of the time
- Some of the time
- All of the time
45.Have you ever been fired?
- No
- Yes
46.Do you plan any career or job changes in the near future?
- No
- Yes
47. How do/will you discipline a child in your care?
- Spanking
- Lecturing
- Rational discussion
- Consistently use reasonable consequences
- Ignore the child’s misbehavior
- Discipline according to how I feel at the time
- Physical restraint, e.g., strap down in crib
- Make rules and consequences clear in advance
- Take away privileges
- Physical punishment other than spanking
- Use “time outs”
- Raise my voice
- Send child to their room
- Tell child they are grounded
- Tell child they should be ashamed
- Threaten punishment in the future
- Tell child how angry they make me
- Other:
48. What is the overall condition of your health?
- Excellent
- Good
- Fair
- Poor
49. Have you ever been hospitalized or had surgery?
- No
- Yes
50. Are you currently taking any medication(s)?
- No
- Yes
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 = SELF2 = PARENT(S)3 = SIBLING(S)4 = CHILDREN5 = SPOUSE/PARTNER
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 = SELF2 = PARENT(S)3 = SIBLING(S)4 = CHILDREN5 = SPOUSE/PARTNER
Diabetes
Cancer
Asthma
Ulcers
Colitis
Alcoholism
Depression
Schizophrenia
Arthritis
Frequent headaches
Hearing loss
Insomnia
Tuberculosis
Drug addiction
Bipolar illness
Eating disorder
Seizures
Kidney disease
Impaired sight
Sickle cell anemia
Thyroid condition
Developmental disability
Attention deficit disorder
Sexually transmitted disease
High blood pressure
High cholesterol
Allergies
Heart condition
Intellectual disability
Anxiety/Panic attacks
Infertility/Sterility
Other condition(s) not listed:
I affirm that the information given in this questionnaire is correct to the best of my ability.
Signature:*
Date:*
Date Format: MM slash DD slash YYYY