Family Background Questionnaire

Office Use Only Client Name CSC Contract # Medical Record # Client ID#

FAMILY BACKGROUND QUESTIONNAIRE

This questionnaire collects information about your family. Please read and answer every question in this booklet. All information provided will be treated in strict confidence and will not be made available to any other source without your written approval.

*Practitioner Name Today’s Date

PRIMARY CAREGIVER

*Name HB Client ID

*Date of birth *Gender Male Female

*Participant Consent for Triple P on file? Yes No

Address

City State *Zip

Work Phone Home Phone Cell Phone

*Total Number of Children in the Household: *Relationship to the primary child Mother (biological or adoptive) Father (biological or adoptive) Step-mother Step-father Foster mother Foster father Legal Guardian Grandparent Sibling Other (please describe) Current marital status Married Separated Divorced Never married Widow/er *Race American Indian or Alaskan Native Asian Black Multi-Racial Native Hawaiian or Pacific Islander Some Other Race White Unknown *Ethnicity African American Caribbean Caucasian/European Haitian Hispanic/Latino Mayan Other Unknown Triple P Pathways Pre-Assessment Office Use Only Client Name CSC Contract # Medical Record # Client ID# Primary Language Arabic Chinese Dutch English French German Greek Haitian Creole Italian Japanese Korean Mayan Dialect Portuguese Russian Spanish Tagalog Vietnamese Other Highest level of education Bachelors Sixth Grade or less Associate Post Graduate High School Diploma/GED or Equivalent Some College/No Degree No High School Diploma/GED Equivalent Vocational Degree/Certificate *Which best describes the household in which your child is presently living? Original family (both biological or adoptive parents) Step-family (two parents, one being a step-parent or live in companion) Single parent family – mother only Single parent family – father only Foster Family Extended Family/Grandparent Other (please describe) Are you currently employed? Yes No If yes, how many hours per week? 1-10 hours 11-20 hours 21-30 hours 31-40 hours 41 + hours

YOUR HEALTH In the last 6 months have either you or your partner sought professional assistance from any of the following? Self Partner Psychologist Yes No Yes No Psychiatrist Yes No Yes No Counselor Yes No Yes No Social Worker Yes No Yes No Other Professional Yes No Yes No If yes, please specify

Triple P Pathways Pre-Assessment Office Use Only Client Name CSC Contract # Medical Record # Client ID# PRIMARY CHILD HB Client ID

*Name *Date of birth

*Gender Male Female

Age today years

Race American Indian or Alaskan Native Asian Black Multi-Racial Native Hawaiian or Pacific Islander Some Other Race White Unknown Ethnicity African American Caribbean Caucasian/European Haitian Hispanic/Latino Mayan Other Unknown Primary Language Arabic Chinese Dutch English French German Greek Haitian Creole Italian Japanese Korean Mayan Dialect Portuguese Russian Spanish Tagalog Vietnamese Other

PRIMARY CHILD’S HEALTH Does your child experience any of the following? A vision or hearing impairment Yes No A severe chronic illness that results in regular hospitalization Yes No A physical disability Yes No A learning disability Yes No A developmental delay Yes No A restrictive/therapeutic diet Yes No If yes to any of the above, please provide details

Triple P Pathways Pre-Assessment Office Use Only Client Name CSC Contract # Medical Record # Client ID# Is your child having regular contact with another professional or government agency for emotional or behavioral problems? Yes No If yes, please describe

Triple P Pathways Pre-Assessment Office Use Only Client Name CSC Contract # Medical Record # Client ID#

SECONDARY CAREGIVER

HB Client ID

Address if different from above

City State Zip

*Relationship to the primary child Mother (biological or adoptive) Father (biological or adoptive) Step-mother Step-father Foster mother Foster father Legal Guardian Grandparent Sibling Other (please describe)

Current marital status Married Separated Divorced Never married Widow/er Race American Indian or Alaskan Native Asian Black Multi-Racial Native Hawaiian or Pacific Islander Some Other Race White Unknown Ethnicity African American Caribbean Caucasian/European Haitian Hispanic/Latino Mayan Other Unknown Primary Language Arabic Chinese Dutch English French German Greek Haitian Creole Italian Japanese

Korean Mayan Dialect Portuguese Russian Spanish Tagalog Vietnamese Other Highest level of education (if applicable) Bachelors Sixth Grade or less Associate Post Graduate High School Diploma/GED or Equivalent Some College/No Degree No High School Diploma/GED Equivalent Vocational Degree/Certificate Are you currently employed? Yes No If yes, how many hours per week? 1-10 hours 11-20 hours 21-30 hours 31-40 hours 41 + hours

OTHER FAMILY MEMBER INFORMATION

HB Client ID

Gender Male Female

HB Client ID

Gender Male Female

OTHER FAMILY MEMBER INFORMATION

HB Client ID

Gender Male Female

HB Client ID

Gender Male Female

Triple P Pathways Pre-Assessment Office Use Only Client Name CSC Contract # Medical Record # Client ID# DEPRESSION ANXIETY STRESS SCALES

Please read each statement and mark the number which indicates how much the statement applied to you over the past week. There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows: 0 Did not apply to me at all 1 Applied to me to some degree, or some of the time 2 Applied to me a considerable degree, or a good part of the time 3 Applied to me very much, or most of the time

1. I found it hard to wind down. 0 1 2 3 2. I was aware of dryness of my mouth. 0 1 2 3 3. I couldn’t seem to experience any positive feeling at all. 0 1 2 3 4. I experienced breathing difficulty (e.g. excessively rapid breathing, breathlessness) in the absence of physical exertion. 0 1 2 3 5. I found it difficult to work up the initiative to do things. 0 1 2 3 6. I tended to over-react to situations. 0 1 2 3 7. I experienced trembling (e.g. in the hands). 0 1 2 3 8. I felt that I was using a lot of nervous energy. 0 1 2 3 9. I was worried about situations in which I might panic and make a fool of myself. 0 1 2 3 10. I felt that I had nothing to look forward to. 0 1 2 3 11. I found myself getting agitated. 0 1 2 3 12. I found it difficult to relax. 0 1 2 3 13. I felt down-hearted and blue. 0 1 2 3 14. I was intolerant of anything that kept me from getting on with what I was doing. 0 1 2 3 15. I felt I was close to panic. 0 1 2 3 16. I was unable to become enthusiastic about anything. 0 1 2 3 17. I felt I wasn’t worth much as a person. 0 1 2 3 18. I felt that I was rather touchy. 0 1 2 3 19. I was aware of the action of my heart in the absence of physical exertion (e.g. sense of heart rate increase, heart missing a beat. 0 1 2 3 20. I felt scared without any good reason. 0 1 2 3 21. I felt that life was meaningless. 0 1 2 3

Note. From Manual for the Depression Anxiety Stress Scales (2nd Ed.), by S.H. Lovibond and P.F. Lovibond, 1995, Sydney, NSW: Psychology Foundation of Australia. Copyright 1995 by the Psychology Foundation of Australia Inc. Reprinted with permission.

*STRENGTHS AND DIFFICULTIES QUESTIONNARIE SCORES

1. Emotional Symptom Scale Score

2. Conduct Problems Scale Score

3. Hyperactivity Scale Score

4. Peer Problems Scale Score

5. Prosocial Scale Score

*The Strengths and Difficulties Questionnaire and Scoring Tool are located in the back of the Triple P manual. It can also be downloaded in other languages at www.sdqinfo.org.

Triple P Pathways Pre-Assessment Office Use Only Client Name CSC Contract # Medical Record # Client ID# PARENTING SCALE

At one time or another, all children misbehave or do things that could be harmful, that are “wrong”, or that parents do not like. Examples include: hitting someone, whining, throwing food, forgetting homework, not picking up toys, lying, having a tantrum, refusing to go to bed, wanting a cookie before dinner, running into the street, arguing back, coming home late.

Parents have many different ways or styles of dealing with these types of problems. Below are items that describe some styles of parenting. For each item, circle the number that best describes your style of parenting during the past 2 months with your child.

Sample Item At meal time… I decide how much my I let my child decide 1 2 3 4 5 6 7 how much to eat. child eats.

1. When my child misbehaves… I do something I do something about it 1 2 3 4 5 6 7 right away. later.

2. Before I do something about a problem… I give my child I use only one reminder 1 2 3 4 5 6 7 several reminders or or warning. warnings.

3. When I am upset or under stress… I am no more picky than I am picky and on my 1 2 3 4 5 6 7 child’s back. usual.

4. When I tell my child not to do something… I say very little. I say a lot. 1 2 3 4 5 6 7

5. When my child pesters me… I can ignore the I can’t ignore the 1 2 3 4 5 6 7 pestering. pestering.

6. When my child misbehaves… I don’t get into an I usually get into a 1 2 3 4 5 6 7 long argument with argument my child. 7. I threaten to do things that… I am sure I can I know I won’t 1 2 3 4 5 6 7 carry out. actually do. 8. I am the kind of parent that… Sets limits on what Lets my child do 1 2 3 4 5 6 7 my child is allowed whatever he or she to do. wants.

9. When my child misbehaves… I give my child a I keep my talks short and 1 2 3 4 5 6 7 long lecture. to the point.

10. When my child misbehaves… I raise my voice or I speak to my child yell. calmly. 1 2 3 4 5 6 7

11. If saying no doesn’t work right away… I take some other I keep talking and trying 1 2 3 4 5 6 7 kind of action. to get through to my child. 12. When I want my child to stop doing something… I firmly tell my I coax or beg my 1 2 3 4 5 6 7 child to stop. child to stop. 13. When my child is out of my sight… I often don’t know I always have a good 1 2 3 4 5 6 7 what my child is idea of what my child doing. is doing.

14. After there has been a problem with my child… Things get back to I often hold a 1 2 3 4 5 6 7 grudge. normal quickly. 15. When we are not at home… I handle my child I let my child get away 1 2 3 4 5 6 7 the way I do at with a lot more. home.

16. When my child does something I don’t like… I often let it go. I do something 1 2 3 4 5 6 7 about it every time it happens. 17. When there is a problem with my child… Things build up and I Things don’t get out 1 2 3 4 5 6 7 do things I don’t of hand. mean to do.

18. When my child misbehaves, I spank, slap, grab, or hit my child… Never or rarely. Most of the time. 1 2 3 4 5 6 7

19. When my child does not do what I ask… I take some other I often let it go or 1 2 3 4 5 6 7 end up doing it action. myself. 20. When I give a fair threat or warning… I often don’t carry it I always do what I 1 2 3 4 5 6 7 out. said. 21. If saying “No” does not work… I take some other 1 2 3 4 5 6 7 I offer my child kind of action. something nice so he/she will behave. 22. When my child misbehaves… I handle it without I get so frustrated or 1 2 3 4 5 6 7 getting upset. angry that my child can see I’m upset.

23. When my child misbehaves… I make my child tell I say “No” or take me why he/she did it. some other action. 1 2 3 4 5 6 7

24. If my child misbehaves and then acts sorry… I let it go that time. I handle the problem like 1 2 3 4 5 6 7 I usually would. 25. When my child misbehaves… I almost always use bad I rarely use bad 1 2 3 4 5 6 7 language or curse. language. 26. When I say my child can’t do something… I let my child do it 1 2 3 4 5 6 7 I stick to what I said. anyway. 27. When I have to handle a problem… I don’t say I am sorry. I tell my child I am 1 2 3 4 5 6 7 sorry about it. 28. When my child does something I do not like, I insult my child, say mean things, or call my child names… Most of the time. Never or rarely. 1 2 3 4 5 6 7

29. If my child talks back or complains when I handle a problem… I give my child a talk about I ignore the 1 2 3 4 5 6 7 complaining and stick not complaining. to what I said. 30. If my child gets upset when I say “No”… I stick to what I said. I back down and give 1 2 3 4 5 6 in to my child.

PARENTS ATTRIBUTIONS FOR CHILD’S BEHAVIOR MEASURE

This questionnaire contains six situations that involve different ways that children can behave. You are asked to imagine your child performing each behavior in each situation. Please complete the questionnaire by reading all of the six situations, and then circling a number on the scale for all the four statements following each situation that indicates how much you strongly disagree or agree with each.

The rating scale is as follows: 1 Disagree strongly 2 Disagree 3 Disagree somewhat 4 Agree somewhat 5 Agree 6 Agree strongly

SITUATION 1 Imagine your child is playing with his/her friend in the next room and you think you hear them fighting. You ask your child what is going on, but there is no reply. You go into the room to check, and at that moment your child hits his/her friend.

My child’s behavior is due to something about my child; for example, because that is the way he/she is 1 2 3 4 5 6 My child intended to behave this way on purpose 1 2 3 4 5 6 The reason my child behaved this way is unlikely to change 1 2 3 4 5 6 My child deserves to be blamed for his/her behavior 1 2 3 4 5 6

SITUATION 2 Imagine shortly after you punish your child, you tell them to play quietly with his/her toys. Very soon after this instruction your child stands up, looks you in the eye, throws a toy at an expensive ornament, breaks it, and then runs away.

My child’s behavior is due to something about my child; for example, because that’s the way he/she is 1 2 3 4 5 6 My child intended to have his way on purpose 1 2 3 4 5 6 The reason my child behaved this way is unlikely to change 1 2 3 4 5 6 My child deserves to be blamed for his/her behavior 1 2 3 4 5 6

SITUATION 3 Imagine after being told to come inside twice, your child responds angrily “No I’m not coming. I don’t have to.”

My child’s behavior is something about my child, for example, because that’s the way he/she is 1 2 3 4 5 6 My child intended to behave this way on purpose 1 2 3 4 5 6 The reason my child behaved this way is unlikely to change 1 2 3 4 5 6 My child deserves to be blamed for his/her behavior 1 2 3 4 5 6

SITUATION 4 Imagine you are in the supermarket and your child asks you for a ride on the merry-go-round. You say “No, I have not got any money for rides today.” Your child reacts by hitting you.

SITUATION 5 Imagine your child is playing outside with a friend, you call out to your child to come inside but he/she doesn’t respond.

SITUATION 6 Imagine you leave your child and his/her friend in the next room to play for a while. After a few minutes you decide to check to se how things are going with the kids. At that moment you see your child throw a toy which breaks an expensive ornament.

RELATIONSHIP QUALITY INDEX

Circle the number that best describes the degree of satisfaction you feel in various areas of your relationship with your partner.

Very Strongly Disagree Neither Agree Strongly Very strongly disagree agree nor agree Strongly disagree disagree agree

1. We have a good relationship 1 2 3 4 5 6 7

2. My relationship with my partner is very stable 1 2 3 4 5 6 7

3. My relationship with my partner is strong 1 2 3 4 5 6 7

4. My relationship with my partner makes me happy 1 2 3 4 5 6 7

5. I really feel like part of a team with my partner 1 2 3 4 5 6 7

6. All things considered, what degree of happiness best describes your relationship?

1 2 3 4 5 6 7 8 9 10 Unhappy Happy Perfectly happy

Note. From “Measuring marital quality: A look at the dependent variable,” by R. Norton, 1983, Journal of Marriage and the Family, 45, p. 147. Copyright 1983 by the National Council on Family Relations, US Adapted with permission.

Triple P Pathways Pre-Assessment