Assess Your Child's Well-Being

Since your CHILD was born: Have you and your partner separated or divorced?

Since your CHILD was born: Has your child lived with anyone who was depressed or mentally ill, or who attempted suicide?

Since your CHILD was born: Has your child lived with anyone who was a problem drinker or used street drugs?

Since your CHILD was born: Has your child lived with anyone who has been to prison?

Since your CHILD was born: Has your child ever witnessed anyone in the home (patents or adults) push, grab, slap, or throw things at each other and/or witnessed anyone kick, bite, hit with a fist, or hit each other with something hard, or ever witness people threatening each other with a weapon, such as a knife or a gun?

Since your CHILD was born: Since your child was born, have there been times when your child has not had enough to eat, has not had anyone take him/her to the doctor, or have any of his/her caregivers been too drunk or high to take care of him/her?

Since your CHILD was born: Since your child was born, has a parent or other adults in your home sworn at, insulted or put your child down, or acted in a way that made your child afraid that he/she might be physically hurt?

Since your CHILD was born: Did a parent or other adult in your home push, grab, slab, or throw something at your child or ever hit him/her so hard that he/she had marks or was injured?

Since your CHILD was born: Did a parent, adult, or someone at least 5 years older than your child ever touch your child sexually or try to make your child touch them sexually?

Since your CHILD was born: Since your child was born, do you feel as if there has NOT been anyone in his/her family who makes him/her feel special, or that you or his other caregivers have NOT been able to be a source of strength, support or protection for your child?