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 your student's areas strength and opportunity.  Please allocate at least 30 minutes to fully complete all assessment sections during one session.

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

 

Name *
Name
Phone *
Phone
Student's Interest/Views. The student: *
Student's Interest/Views. The student:
1) Believes religion and/or spirituality are very important.
2) Is pleased with the state of our country's leadership.
3) Is more inclined to become an entrepreneur than to become 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 others.
6) Regularly helps siblings and other classmates/ children.
7) Enjoys volunteering to help those less fortunate (feeding homeless, 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 (toys, 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.
12) Tends to work on a project until it is completed to perfection.
About Parents (Answer the following questions about the Mother and/or Father. Parent(s): *
About Parents (Answer the following questions about the Mother and/or Father. Parent(s):
1) Are considered middle or upper class.
2) Have a history of drug/alcohol abuse.
3) Have a history of Attention Deficit Disorder or Autism.
4) Have experienced sexual abuse or trauma.
5) Have a history of domestic violence/aggression/spousal abuse
6) Have experienced depression, anxiety, or other behavioral health challenges.
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) Has a record of arrest, parole, or probation.
11) Is currently take regular pain medication.
About Siblings (Answer the following questions about ANY of the student's brothers or sisters). A sibling: *
About Siblings (Answer the following questions about ANY of the student's brothers or sisters). A sibling:
1) Has a history of drug/alcohol abuse.
2) Has 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 challenges.
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) (Another sibling) receives significantly more attention/praise, due to excelling in academics, sports, popularity, etc.
About Extended Family (Answer the following questions about ANY family member who is the student's grandparent, aunt, uncle, or cousin). An extended family member: *
About Extended Family (Answer the following questions about ANY family member who is the student's grandparent, aunt, uncle, or cousin). An extended family member:
1) Has a history of drug/alcohol abuse.
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 challenges.
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 serious trauma to the student (violence, sexual, etc.).
Student's Early Childhood (Age 0 - 7): *
Student's Early Childhood (Age 0 - 7):
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. (If so, please elaborate in Additional Information section.)
8) First seven years were generally normal and full of joy.
9) Was raised by both mother and father during first seven years.
10) During first seven years, student never witnessed parents fighting. Student only recalls a peaceful relationship between parents.
Youth (Elementary Through High School): *
Youth (Elementary Through High School):
1) Overall elementary, middle, and high school experience was 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 part of this time.
8) Was respectful and rarely lost temper.
9) Was not defiant and did not regularly 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.
14) Had no significant memory challenges and seldom misplaced things.
15) Did not talk excessively, blurt things out, or interrupt others when speaking.
16) Generally speaking, student had high self-esteem.
17) Was never suspended or expelled from school.
18) Was never a part of a street gang.
19) Has shown no evidence of being bullied.
20) Showed no evidence of experiencing depression, anxiety, or other behavioral health challenges.
21) During these years, showed no evidence of ever having thoughts of or attempting to seriously hurt self (cutting, suicide, etc.).
22) Has never had a problem with hearing voices or seeing things that were not there.
23) Was never treated, taken medication for, or hospitalized for behavioral health challenges.
24) During these years, student did not smoke cigarettes.
25) During these years, student did not regularly use alcohol or drugs.
26) Was never arrested or involved with juvenile court.
27) Was never abusive to others (bullying, threatening, harming, etc.)
27) During these years, student never experienced sexual abuse, as a victim or perpetrator.
Student's Behavior. Student has (or had): *
Student's Behavior. Student 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 challenges.
6) A history of eating disorder, obesity, anorexia, etc.
7) Experienced or observed deep trauma (crime, abuse, homelessness, violence, etc.).
8) A history or self-harm (cutting, suicidal thoughts/attempts, etc.).
9) A current prescription for regular medication.
10) Tendency toward screaming, crying, or temper tantrums, when agitated or frustrated.
11) Tendency to prefer isolation, rather than mixing during social settings.
12) Has a record of arrest, parole, or probation.