Form AD918 "Family Assessment Questionnaire Ii" - California

What Is Form AD918?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2003;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AD918 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form AD918 "Family Assessment Questionnaire Ii" - California

1333 times
Rate (4.7 / 5) 66 votes
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FAMILY ASSESSMENT QUESTIONNAIRE II
PRINT NAME:
DATE:
Have you experienced any of the following during the past two years? (Check all that apply).
1.
Marital reconciliation
Divorce
Separation from spouse or partner
Fired from job
Change in health of a family member
Death of a child, family member or close friend
Pregnancy
Financial problems
Infertility treatment
Personal trauma, injury or illness
Change to a different line of work
None of the above
2.
Have any of the following behaviors or substances presented concerns for you or your spouse or partner?
(Check all that apply)
SELF
SPOUSE OR PARTNER
N/A (No spouse or partner) ..........................................................................................................................
Gambling......................................................................................................................................................
Spending ......................................................................................................................................................
Food ............................................................................................................................................................
Sex ..............................................................................................................................................................
Alcohol .........................................................................................................................................................
Drugs ...........................................................................................................................................................
Controlling temper........................................................................................................................................
Smoking .......................................................................................................................................................
Work.............................................................................................................................................................
None of the above........................................................................................................................................
3.
Did your parents abuse alcohol or other forms of substances when you were a child? (Check all that apply)
No
Mother
Father
Stepparent(s)
The person(s) who raised me
4.
Who in your family abuses alcohol or other substances? (Check all that apply)
Self
Mother
Brother(s)
Aunt(s)
Cousin(s)
Spouse or Partner
Father
Sister(s)
Uncle(s)
In-law(s)
Son(s)
Stepmother
Grandmother
Niece(s)
I am not sure
Daughter(s)
Stepfather
Grandfather
Nephew(s)
Other(s):__________________
5.
If alcohol/substance abuse has been a family problem, how have you dealt it? (Check all that apply)
It has not been a family problem
It has not bothered me
I confronted the abuser
I confided in trusted friends or my spouse or partner
I educated myself on the subject
I sought counseling
The family member is in recovery
It is still difficult for me
I attend a 12-step program
I have never told anyone about the incident(s)
Other:__________________________________________________
AD 918 (11/03)
Page 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FAMILY ASSESSMENT QUESTIONNAIRE II
PRINT NAME:
DATE:
Have you experienced any of the following during the past two years? (Check all that apply).
1.
Marital reconciliation
Divorce
Separation from spouse or partner
Fired from job
Change in health of a family member
Death of a child, family member or close friend
Pregnancy
Financial problems
Infertility treatment
Personal trauma, injury or illness
Change to a different line of work
None of the above
2.
Have any of the following behaviors or substances presented concerns for you or your spouse or partner?
(Check all that apply)
SELF
SPOUSE OR PARTNER
N/A (No spouse or partner) ..........................................................................................................................
Gambling......................................................................................................................................................
Spending ......................................................................................................................................................
Food ............................................................................................................................................................
Sex ..............................................................................................................................................................
Alcohol .........................................................................................................................................................
Drugs ...........................................................................................................................................................
Controlling temper........................................................................................................................................
Smoking .......................................................................................................................................................
Work.............................................................................................................................................................
None of the above........................................................................................................................................
3.
Did your parents abuse alcohol or other forms of substances when you were a child? (Check all that apply)
No
Mother
Father
Stepparent(s)
The person(s) who raised me
4.
Who in your family abuses alcohol or other substances? (Check all that apply)
Self
Mother
Brother(s)
Aunt(s)
Cousin(s)
Spouse or Partner
Father
Sister(s)
Uncle(s)
In-law(s)
Son(s)
Stepmother
Grandmother
Niece(s)
I am not sure
Daughter(s)
Stepfather
Grandfather
Nephew(s)
Other(s):__________________
5.
If alcohol/substance abuse has been a family problem, how have you dealt it? (Check all that apply)
It has not been a family problem
It has not bothered me
I confronted the abuser
I confided in trusted friends or my spouse or partner
I educated myself on the subject
I sought counseling
The family member is in recovery
It is still difficult for me
I attend a 12-step program
I have never told anyone about the incident(s)
Other:__________________________________________________
AD 918 (11/03)
Page 1 of 4
6.
what is the average frequency and amount of alcohol that you and your spouse or partner drink?
SELF
SPOUSE OR PARTNER
N/A (No spouse or partner) ..........................................................................................................................
Daily, one to three drinks .............................................................................................................................
Daily, four or more drinks .............................................................................................................................
Several times a week, one to three drinks ...................................................................................................
Several times a week, four or more drinks...................................................................................................
Several times a month, one to three drinks .................................................................................................
Several times a month, four or more drinks .................................................................................................
Several times a year, one to three drinks ....................................................................................................
Several times a year, four or more drinks ....................................................................................................
Never drink alcohol ......................................................................................................................................
7.
Do you and/or your spouse or partner ever drink alcohol first thing in the morning?
Yes, myself
Yes, my spouse or partner
No
8.
Was there ever a time when you and/or your spouse or partner were drinking too much alcohol?
Yes, myself
Yes, my spouse or partner
No
9.
As a direct or indirect result of alcohol use, have you or your spouse or partner experienced any of the following?
(Check all that apply)
SELF
SPOUSE OR PARTNER
N/A (No spouse or partner) ..........................................................................................................................
Legal difficulty ..............................................................................................................................................
Absence from work ......................................................................................................................................
Accidents .....................................................................................................................................................
Loss of a job.................................................................................................................................................
Health problems ...........................................................................................................................................
Violent behavior ...........................................................................................................................................
Arguments with family or friends ..................................................................................................................
Inpatient alcohol treatment program ............................................................................................................
Outpatient alcohol treatment program .........................................................................................................
None of the above........................................................................................................................................
10. Which of the following have you or your spouse or partner used? (Check all that apply)
SELF
SPOUSE OR PARTNER
N/A (No spouse or partner) ..........................................................................................................................
Barbiturates/Sleeping Pills ...........................................................................................................................
Methamphetamines/Amphetamines/Speed .................................................................................................
Over the counter diet pills/other stimulants ..................................................................................................
Hallucinogens/LSD/Psiloybin/Mescaline ......................................................................................................
Inhalants/Glue/Solvents ...............................................................................................................................
Quaaludes....................................................................................................................................................
Methadone ...................................................................................................................................................
Heroin/Morphine/Opium ...............................................................................................................................
Cocaine/Crack .............................................................................................................................................
Marijuana/Hashish .......................................................................................................................................
Tranquilizers ................................................................................................................................................
Pain Pills ......................................................................................................................................................
PCP..............................................................................................................................................................
Club Drugs/Ecstacy/GHB/Rohypnol/Ketamine ............................................................................................
None of the above........................................................................................................................................
Page 2 of 4
11. As a direct or indirect result of prescription or illegal drug use, have you and/or your spouse or partner experienced any of the
following? (Check all that apply)
SELF
SPOUSE OR PARTNER
N/A (No spouse/partner) ..............................................................................................................................
Legal difficulties ...........................................................................................................................................
Absence from work ......................................................................................................................................
Accidents .....................................................................................................................................................
Loss of a job.................................................................................................................................................
Health problems ...........................................................................................................................................
Violence .......................................................................................................................................................
Arguments with family or friends ..................................................................................................................
Inpatient drug treatment program ................................................................................................................
Outpatient drug treatment program..............................................................................................................
None of the above........................................................................................................................................
12. When you were a child, did any person (adult or child) ever force, trick or coerce you into having any kind of sexual contact
with him/her?
Yes
No
I don’t know if this ever happened to me
13. When you were a child, were you ever hit, pushed, whipped, bitten, punched, slapped or burned in a way that resulted in
injuries being left on your body?
Yes
No
I don’t know if this ever happened to me
14. As an adult, have you ever been sexually abused, assaulted or molested?
Yes
No
15. As an adult, have you ever been physically abused, assaulted or battered?
Yes
No
16. Who in your family has been sexually abused, assaulted or molested as an adult or child? (Check all that apply)
I am not sure
Mother
Brother(s)
Aunt(s)
Cousin(s)
Spouse or Partner
Father
Sister(s)
Uncle(s)
In-law(s)
Son(s)
Stepmother
Grandmother
Niece(s)
No family member
Daughter(s)
Stepfather
Grandfather
Nephew(s)
Other(s):_______________
17. Who in your family has been physically abused, assaulted or battered as an adult or child? (Check all that apply)
I am not sure
Mother
Brother(s)
Aunt(s)
Cousin(s)
Spouse or Partner
Father
Sister(s)
Uncle(s)
In-law(s)
Son(s)
Stepmother
Grandmother
Niece(s)
No family member
Daughter(s)
Stepfather
Grandfather
Nephew(s)
Other(s):_______________
18. If you or anyone in your family experienced physical or sexual abuse, how was the issue dealt with? (Check all that apply)
N/A
It has not bothered me
The abuser was confronted
I confided in my spouse/partner or friends
I educated myself on the subject
I sought counseling
I reported it to Child Protective Services
It is still difficult for me
I reported the incident to law enforcement
The abuse was never talked about
Other:____________________________________________________________________________________________________
Page 3 of 4
19. Have you or anyone in your family ever been suspected of, investigated for, charged with, or convicted of physically or
sexually abusing children? (Check all that apply)
Self
Mother
Brother(s)
Aunt(s)
Cousin(s)
Spouse or Partner
Father
Sister(s)
Uncle(s)
In-law(s)
Son(s)
Stepmother
Grandmother
Niece(s)
I am not sure
Daughter(s)
Stepfather
Grandfather
Nephew(s)
Other(s):__________________
20. Have you or anyone in your family ever been suspected of, investigated for, charged with, or convicted of physically or
sexually assaulting another adult? (Check all that apply)
Self
Mother
Brother(s)
Aunt(s)
Cousin(s)
Spouse or Partner
Father
Sister(s)
Uncle(s)
In-law(s)
Son(s)
Stepmother
Grandmother
Niece(s)
I am not sure
Daughter(s)
Stepfather
Grandfather
Nephew(s)
Other(s):__________________
21. Have you or anyone in your household ever been struck by anyone living in the home?
Yes
No
22. Has your spouse or partner ever hurt you physically by actions such as pushing, slapping, kicking, punching, biting, choking,
throwing objects, cutting or forcing you to have sexual contact that was against your will?
N/A
Never
Once
Twice
Several Times
Frequently
23. If you needed help from a counselor or therapist, what were your reasons? (Check all that apply)
No counseling/therapy
Drug/Alcohol problems
Stress
Depression
Relationship problems
Job related problems
Family problems
Traumatic event
School problems
Eating Disorder
Parenting problems
Other:_______________________
24. Have you and/or your spouse or partner ever been hospitalized in a psychiatric facility?
Yes, self
Yes, spouse or partner
No
25. Does anyone in your family have a history of mental illness? (Check all that apply)
Self
Mother
Brother(s)
Aunt(s)
Cousin(s)
Spouse or Partner
Father
Sister(s)
Uncle(s)
In-law(s)
Son(s)
Stepmother
Grandmother
Niece(s)
I am not sure
Daughter(s)
Stepfather
Grandfather
Nephew(s)
Other(s):__________________
I affirm that the information given in this questionnaire is correct to the best of my ability.
SIGNATURE
DATE
Page 4 of 4
Page of 4