Safe Families Alaska Home Study Survey
Please note that the answers to your questions do not qualify OR disqualify you from volunteering with Safe Families for Children. Our staff simply wants to get to know you and your family. A more in-depth conversation will be had at your home certification visit.
Name
*
First Name
Last Name
Please have everyone in your house, over the age of 18, fill this form out individually.
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Current Child Welfare Participation
Are you currently a licensed Foster Home in the State of Alaska?
Yes
No
Support System
Who can help you with childcare?
If you had a crisis, who would you call?
Family Dynamics
the following questions pertain to the children currently living in your home
Sibling Relationships
Excellent
good
Fair
Poor
Health of Children
Excellent
good
Fair
Poor
Behavior of Children
Excellent
good
Fair
Poor
Discipline of Children
Time out
Spanking
Loss of Privileges
Grounding
Other
Do your children have special needs? (Check all that apply)
Learning
Development
Health
Mental Health
Explain special needs indicated
Children's view of having a Safe Family guest in your home
Is there anyone over the age of 18 living at your residence?
Support of Placing Parents
Are you interested in developing a relationship with the parent of the children in your care?
Yes
No
Safe Families Child Information
Please know you can change this at any point
What ages are you interested in having in your home?
How many children are you interested in having in your home?
What gender(s) are you interested in having in your home?
Either
Female
Male
Describe you plans for discipline and behavior management of the children staying in your home
What rules are important in your family?
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Individual Assessment
Family Background
Which of the following has occurred in your family of origin?
Domestic Violence
Physical Abuse
Sexual Abuse
Emotional Abuse
Mental Illness
Drug Abuse
Alcohol Abuse
Divorce
Traumatic Events
Bankruptcy
Legal Difficulties
Other
Who primarily raised you?
Were you ever separated from either or both of your parents during your childhood for any of the following reasons?
None apply
Parents seperated
Parents divorced
Death of parent(s)
Abandoned by parents
Parent(s) long-term hospitalization
Parent(s) in Military
Parent(s) in prison
Removed from your home by police
Which words best describe your childhood (before teenage)?
Painful
Happy
Fun
Wonderful
Stable
Confusing
Frightening
Chaotic
Traumatic
Spoiled
Enjoyable
Sad
Exciting
Unhappy
Carefree
Stimulating
Other
Which words best describe your teenage years?
Painful
Happy
Fun
Wonderful
Stable
Confusing
Frightening
Chaotic
Traumatic
Spoiled
Enjoyable
Sad
Exciting
Unhappy
Carefree
Stimulating
Other
Which words best describe your young adult years?
Painful
Happy
Fun
Wonderful
Stable
Confusing
Frightening
Chaotic
Traumatic
Spoiled
Enjoyable
Sad
Exciting
Unhappy
Carefree
Stimulating
Other
Briefly describe the personal characteristics of your mother or primary female caretaker while growing up
Briefly describe the personal characteristics of your father or primary male caretaker while growing up
How were you disciplined as a child?
Check the boxes that best describe what you were like as a child (before teenage years)
Happy
Tempermental
Stubborn
Unhappy
Aggressive
Fearful
Awkward
Self-Confident
Friendly
Calm
Serious
Hyperactive
Responsible
Sad
Irresponsible
Anxious/Nervous
Active
Funny
Rebellious
Disobedient
Outgoing
Sickly
Insecure
Obedient
Check the boxes that best describe what you were like as a teenager
Happy
Tempermental
Stubborn
Unhappy
Aggressive
Fearful
Awkward
Self-Confident
Friendly
Calm
Serious
Hyperactive
Responsible
Sad
Irresponsible
Anxious/Nervous
Active
Funny
Rebellious
Disobedient
Outgoing
Sickly
Insecure
Obedient
Are there issues, traumatic incidents, or accidents from your childhood that currently cause you distress?
Did you seek mental health services as a child, teen, or young adult?
If you were married previously, how did your marriage(s) end?
Have you ever been in a custody dispute?
Loss History
What losses have you experienced and how have you responded to these losses?
Employment, Education, and Volunteer History
In the past 5-10 years what kind of work have you done? What kind of work are you currently doing?
Please describe your educational history
Please describe your volunteer history
Cultural Experiences
Discuss any experiences with different cultures, discrimination, and prejudice during childhood and adulthood
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Is there anything else you would like to share with our staff?
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