Community Health Partners developed this one page assessment to be used with clients in order to document challenges families have dealt with during the past 5 years. Today's families deal with many challenges. While some of these concerns are only temporary, they each can cause stress and hardships.
Please check any of the challenges that your family has faced within the past 5 years.
____ Moved (within the past 5 years)
____ Unemployed or underemployed
____ Depression in self or family member
____ Drug or alcohol dependency in self or family member
____ Dropped out of school
____ Lacks GED or high school diploma
____ Single parent
____ No car
____ Major physical health concerns in self or family member
____ Child removed from home
____ Were you a teen parent
____ No driver's license
____ Family member imprisoned or in jail
____ Stayed in a women's shelter
____ English is your second language
Click here to download the PDF version of this questionnaire.