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Self-Assessment

Take your time to answer all of the applicable questions below.

The self assessment questionnaire is designed to help you analyse your life and your family relationships and should be used as a tool to help you make the necessary changes in your life 

Your name:

Your email:

General info

Name of young person:

Age: 

Family members (parents, siblings, etc.) and ages:

3 main friends:

Music likes:

Food likes:

Hobbies:

Interests:

Aspirations:

Social beliefs:

Achievements to date: 

Experiences at school (good or bad, with reasons): 

Who they admire (and why): 

Ask them to list 3 positives about themselves:

Physical and emotional health and wellbeing

Sports played past/present:

Exercise regime now (if any):

Body shape:

Diet assessment
List of food/drink (healthy and unhealthy): 

Any smoke/alcohol/drugs: 

Relaxation techniques: 

Anger

Do they relax and understand positive self talk: 

When was last time they were angry:

What made them angry: 

How did they feel when angry: 

How did they behave when angry: 

How did you respond:

What are their triggers: 

How did they calm down:

What technique did they use:

What can they do different next time:

What can you do different:

Violence

Are they at all violent:

If yes, when was the last occasion:

History of violence and frequency:

Type(s) of violence displayed: 

Weapons used (if applicable): 

Threats made before violence: 

Trigger signs: 

Patterns of violence (time of day, particular events. after visits, etc.):

Exposure to violence from family members or other source:  

Drug/alcohol use

History of drink/drugs: 

Frequency: 

Type of drugs/drink:

Any drugs tests:

Behaviour before and after:

Criminal behaviour

Previous offending warnings, cautions etc:

Frequency of offending: 

Type of crime committed: 

Any pattern of offending:

Location/s of offending: 

Respect and relationships

Please ask them to answer the following questions honestly

How would you like to be treated and why:

What does respect mean to you:

How do you earn respect: 

How do you show respect:

What happens if someone doesn’t respect you: 

What happens if you don’t respect someone else:

How do you show respect in a relationship: 

Where do you feel you fit in society:

Who do you associate with:

History of DV

If so victim/offender or both:

Current relationship status: 

Emotional behaviour

Diagnosed emotional difficulties Y/N:

Under GP/mental health practitioner Y/N: 

Self Harm History

Type of self harm: 

Method and implements used:

Frequency:

Key times:

Emerging pattern:

Triggers:

Regular injuries: 

School behaviour

School attendance score:

Anything of note in school reports: 

Change in behaviour at school:

Final thoughts:

What outcomes do you want as a parent or carer:

Relationship with your teen now on a score of 1-10 (1 being low and 10 high): 

What ways have you tried to improve relationships with your teen: