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

____ Homeless

____ 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.