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System Info

Completed

Yes

Record ID

Participant

The Risk and Protective Inventory

Due Date

The following questions will help us get to know your child so that we may best serve them. Please be honest and answer each question and circle only one response. This information won’t disqualify your child from participating in the program. Knowing more about these areas can help us to find the right Big for your child and better support the match relationship. You will have an opportunity to further discuss these questions. Thank you for your time!

1. My child is involved in a positive, constructive activity, such as a hobby or sport, a club or school organization, or employment.

2. My child cares about his/her religious or spiritual beliefs or practices.

3. My child is proud to be a member of his/her racial, ethnic, or cultural group.

4. My child has been arrested in the last 12 months.

5. In the last 12 months, my child has run away from home for 24 hours or more.

6. My child smoked or chewed tobacco in the past 12 months.

7. My child drank alcohol in the past 12 months.

8. My child used drugs in the past 12 months (this may include marijuana and/or prescription drugs not prescribed to him/her).

9. My child is physically aggressive.

10. My child can usually think of several good solutions to problems with friends or other children.

11. My child continues to work at things even when he/she says it is hard to do or challenging.

12. I have been told by a professional that my child has a mental health issue, or he/she is currently under the care of a mental health care provider (a therapist or counselor).

13. My child seems lonely, sad, or cries a lot.

14. My child worries, which affects his/her daily life.

15. My child has difficulty controlling his/her feelings.

16. My child feels positively about his/her future.

17. Overall, my child is satisfied with his/her life.

18. My child is easygoing and rarely stays upset for too long.

19. My child has been suspended from school two or more times in the last 12 months.

20. My child has good relationships with his/her teachers.

21. My child misses school often (3 or more times a month).

22. My child is currently failing a class/subject in school or has failed a class/subject in school in the last 6 months.

23. My child tries to do well in school.

24. My child has Attention Deficit Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD).

25. My child has a diagnosed learning disability.

26. My child has a learning difference that makes it difficult to do schoolwork at grade level.

27. My child is learning English as a second language.

28. My child belongs to a nurturing community with supportive adults, such as a faith-based community or tight-knit neighborhood.

29. There are a lot of illegal drugs and/or acts of violence in the neighborhood where my child lives.

30. In the last 12 months, our family has experienced a lot of difficulty paying bills.

31. My child lives in public housing.

32. My child’s neighborhood is a good place for families, with safe outdoor parks and/or community centers with activities.

33. At least one of the adults in our home is currently employed for pay.

34. The household’s total combined family income last year was less than $20,000.

35. My child has a relationship with an adult who is not his/her parent and who cares about him/her as a person and helping him/her be successful.

36. I am usually aware of where my child is if he/she is not at home.

37. My family has clear rules about chores.

38. One or more members of my child’s family (brother/sister, parent or other close relative) has mental health problems.

39. One or more members of my child’s family (brother/sister, parent or other close relative) has a problem with alcoholism or drug use.

40. One or more members of my child’s family (brother/sister, parent or other close relative) is in jail/prison, out on parole or is on probation.

41. My child has experienced homelessness in the last five years.

42. In the last five years, my child or one or more of my child’s brothers or sisters was removed from our home and placed in foster care or with relatives.

43. There have been many fights or arguments in my child’s home in the last 12 months.

44. My child lives with only one parent or caregiver.

45. My child lost contact with an important adult role model in the last 12 months (for example, a parent or other important adult died or moved out of our home).

46. My child has moved to a different home two or more times in the last 12 months.

47. My child is currently living in foster care.

48. I separated from, or broke up with, my spouse/partner in the last year.

49. At least one of the adults who currently live with my child completed high school (graduated from high school or received a GED).

50. My child voluntarily helps others.

51. All of my child’s friends try to do well in school and stay out of trouble.

52. My child is able to work through disagreements with others (listen, express his/her own beliefs, work towards a solution, etc.).

53. My child has been picked on or bullied at school or in their neighborhood in the last 12 months.

54. My child has an Individual Education Plan (IEP) to address his/her learning disability.

55. My child has a close friend who is often in trouble because he/she doesn’t like to follow the rules.

56. My child has a close friend who skips school, uses drugs or alcohol, is in a gang, or has been in serious trouble with the police.

57. My child has the skills needed to make and maintain friendships with peers.

58. It is really important to my child to get revenge when s/he thinks s/he has been wronged.

59. My child cares about other children’s feelings.

If you wish to tell us something else about your child, please write the additional information here:

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