Assessment

Please complete the Assessment to the right as thoroughly as possible and submit.  Your analysis will be completed by our team of well-being professionals and you will receive a Findings Report within 7 days.

Please offer as much detail as you can to help us best understand areas strength and opportunity.  Please allocate at least 30 minutes to fully complete all assessment sections at once.

Additional questions may be included in the Additional Information box at the end of the assessment.

 

Name *
Name
Phone *
Phone
Adult's Interest/Views. The person being assessed: *
Adult's Interest/Views. The person being assessed:
1) Believes religion and/or spirituality are very important.
2) Believes the current state of our country is in good hands.
3) Believes more in entrepreneurship than to working as a life-long employee.
4) Is very committed to exercise and works out for at least 30 minutes, 3 times/week.
5) Has high regard for the views of children and other adults.
6) Regularly helps his/her children, young siblings/family members, and younger children.
7) Enjoys volunteering to help those less fortunate (feeding homeless, gives blood, etc.)
8) Is fascinated in and would like to work more with computers and technology.
9) Enjoys working with his/her hands to build and repair things (home repair, construction, etc.)
10) Enjoys singing/playing an instrument, creating art, dancing, writing poems/stories, etc.
11) Is a strong supporter of the LGBTQ community values and feels everyone is entitled to their own choices.
About Parents (Answer the following questions about the Mother and/or Father. One or both parents: *
About Parents (Answer the following questions about the Mother and/or Father. One or both parents:
1) Were considered middle or upper class, when growing up.
2) Have had an abuse problems with drugs or alcohol.
3) Have had a history of Attention Deficit Disorder or Autism.
4) Have experienced sexual abuse or trauma.
5) Have experienced domestic violence/aggression/spousal abuse
6) Have experienced depression, anxiety, or other behavioral health disorders.
7) Have a history of eating disorder, obesity, anorexia, etc.
8) Have experienced military service-related PTSD (Post Traumatic Stress Disorder).
9) Have a history or self-harm (cutting, suicidal thoughts/attempts, etc.).
10) Have a record of arrest, parole, or probation.
11) Are currently taking regular pain medication.
About Siblings (Answer the following questions about ANY of the adult's brothers or sisters): *
About Siblings (Answer the following questions about ANY of the adult's brothers or sisters):
1) Has had abuse problems with drugs or alcohol.
2) Has had a history of Attention Deficit Disorder or Autism.
3) Has experienced sexual abuse or trauma.
4) Has experienced domestic violence/aggression/spousal abuse
5) Has experienced depression, anxiety, or other behavioral health disorders.
6) Has a history of eating disorder, obesity, anorexia, etc.
7) Has experienced military service-related PTSD (Post Traumatic Stress Disorder).
8) Has had a history or self-harm (cutting, suicidal thoughts/attempts, etc.).
9) Has a record of arrest, parole, or probation.
10) Growing up, received significantly more attention than adult, due to excelling in academics, sports, etc.
About Extended Family (Answer the following questions about ANY family member who is the adult's grandparent, aunt, uncle, or cousin). An extended family member: *
About Extended Family (Answer the following questions about ANY family member who is the adult's grandparent, aunt, uncle, or cousin). An extended family member:
1) Has had an abuse problems with drugs or alcohol.
2) Has had a history of Attention Deficit Disorder or Autism.
3) Has experienced sexual abuse or trauma.
4) Has experienced domestic violence/aggression/spousal abuse
5) Has experienced depression, anxiety, or other behavioral health disorders.
6) Has a history of eating disorder, obesity, anorexia, etc.
7) Has experienced military service-related PTSD (Post Traumatic Stress Disorder).
8) Has a history or self-harm (cutting, suicidal thoughts/attempts, etc.).
9) Has a record of arrest, parole, or probation.
10) Is believed to have inflicted trauma to the adult (violence, sexual, etc.)
Adult's Early Childhood (Age 0 - 7). The adult: *
Adult's Early Childhood (Age 0 - 7). The adult:
1) Was delivered in a hospital, without complication (induction, C-Section, premature, etc.).
2) Was delivered naturally, with a midwife/doula, and without medication.
3) Immediately was fed with dairy-based formula and was never nursed.
4) During pregnancy, student's mother experienced smoking, alcohol, drugs (prescription/non-prescription).
5) During pregnancy, student's mother experienced unusual trauma (domestic violence, eviction/homelessness, court/incarceration, etc.).
6) Birth weight, height, and vital signs were normal.
7) During student's first seven years, student experienced significant health issue(s), causing hospitalization.
8) First seven years were generally easy and full of joy.
9) Was raised by both mother and father during my first seven years.
10) During first seven years, student never witnessed parents fighting. Student only recalls a peaceful parental relationship.
Youth (Elementary Through High School): *
Youth (Elementary Through High School):
1) Overall elementary, middle, and high school experiences were excellent.
2) During school years, academic performance was excellent.
3) During school years, social experience was excellent (plenty of friends, had fun most of the time).
4) Has never received special/remedial education or repeated a grade.
5) Attended public school most of these years.
6) Attended private school for most of these years.
7) Was homeschooled for most of these years.
8) Was respectful and rarely lost temper.
9) Was not defiant and did not challenge parents, teacher, and authority figures.
10) Was not easily angered or annoyed by others.
11) Was never destructive to property or set fires.
12) Was generally honest and rarely in trouble.
13) Followed directions easily and seldom misplaced things.
14) Did not talk excessively, blurt things out, or interrupt others when speaking.
15) Generally speaking, adult had high self-esteem.
16) Was never suspended or expelled from school.
17) Was never a part of a street gang.
18) Was never bullied.
19) Has experienced depression, anxiety, or other behavioral health challenges.
20) During these years, showed no evidence of ever having thoughts of or attempting seriously hurt self (cutting, suicide, etc.).
21) Has never had a problem with hearing voices or seeing things that were not there.
22) Was never treated, taken medication for, or hospitalized for behavioral health.
23) During these years, adult did not smoke cigarettes.
24) During these years, adult never experienced alcohol or drug abuse.
25) Was never arrested or involved with juvenile court.
26) Was never abusive to others (bullying, threatening, harming, etc.)
27) During these years, adult never experienced sexual abuse, as a victim or perpetrator.
Adult (Post-High School). As an adult: *
Adult (Post-High School). As an adult:
1) Overall behavioral health has been excellent.
2) Have earned at least one post-high school level degree.
3) My college/university performance was excellent.
4) I served in the military at least 4 years.
5) After military service, I was honorably discharged.
6) As an adult, my social experience has been excellent (plenty of friends, have fun most of the time).
7) I have been employed or a successful entrepreneur for most of these years.
8) I am respectful and rarely lose my temper.
9) I am not defiant and do not needlessly challenge others or authority figures.
10) I am not easily angered or annoyed by others.
11) I have never destroyed property or set fires.
12) I am generally honest and rarely in trouble.
13) I seldom misplace things.
14) I remember names well.
15) I do not talk excessively, blurt things out, or interrupt others when speaking.
16) Generally speaking, I have high self-esteem.
17) I never joined or was a part of a street gang.
18) I have no memory of being assaulted or getting into physical altercations/fights.
19) I have never experienced depression, anxiety, PTSD, or other behavioral health challenges.
20) I never thought of or attempted to seriously hurt myself (cutting, suicide, etc.).
21) I have never had a problem with hearing voices or seeing things that were not there.
22) I was never treated, taken medication for, or hospitalized for behavioral health.
23) I am not a regular smoker of cigarettes.
24) I smoked cigarettes for at least 2 years, but do not smoke today.
25) I never experienced an alcohol or drug abuse problem.
26) I was never arrested or involved with a serious court case.
27) A have never been abusive to others (domestic violence, threatening others, harming others, etc.)
28) I have never been a victim of or perpetrator of sexual abuse.
Adult's Behavior. Adult has (or had): *
Adult's Behavior. Adult has (or had):
1) An abuse problems with drugs or alcohol.
2) A history of Attention Deficit Disorder or Autism.
3) Experienced sexual abuse or trauma.
4) Witnessed domestic violence/aggression/spousal abuse
5) Personally experienced depression, anxiety, or other behavioral health disorders.
6) A history of eating disorder, obesity, anorexia, etc.
7) Experienced or observed deep trauma (crime, abuse, homelessness, murder, etc.).
8) A history or self-harm (cutting, suicidal thoughts/attempts, etc.).
Is currently take regular pain medication.
9) Tendency toward screaming, fighting, or acting out, when agitated, frustrated, or does net get way.
10) Tendency to spend lots of time in isolation (in room while others socialize, sleeping, on social media, etc.).
11) Has a record of arrest, parole, or probation.