Wff Confidential Cover Sheet Page 5
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7WFF HNF Screening Tool
Respondent Study ID# __ __ __ - __ __ __
S
N
C
ERVICE
EED
RITERIA
I would like to ask you a few more questions about your family and your family’s health and experiences.
SCORING
Y
N
DK
NA
ES
O
I
NSTRUCTIONS
10. In past 12 months have you had any involvement with Child Protective
if 10, 11 or
Services?
:
12 is yes
____
11. Are any of your children currently in foster care?
12. Have any of your children ever been permanently removed from your
household by Child Protective Services?
13. In the past 12 months have you or anyone in your household received
mental health services in a residential psychiatric facility, a hospital
psychiatric ward or an outpatient program? (I
,
#14.)
F NO
SKIP TO
13a. How many times in the past 12 months have you (or they) received
_____
treatment? (
#15.)
T
SKIP TO
IMES
if 13 or 14
14. Have you or anyone in your household ever considered seeking mental
is yes:
health services or been told by others that you or they need mental
____
health services?
15. In the past 12 months have you or anyone in your household received
substance abuse inpatient treatment, intensive outpatient treatment or
detoxification services? (I
,
#16.)
F NO
SKIP TO
15a. How many times in the past 12 months have you (or they) received
_____
treatment? (
#17.)
SKIP TO
TIMES
16. Have you or anyone in your household ever considered seeking
if 15 or 16
substance abuse services or been told by others that you or they need
is yes: ____
substance abuse services?
17. In the past 12 months have you or anyone in your household experienced
if 17 is yes:
any issues related to domestic violence? For example, you were involved
____
in an abusive incident or filed or received a restraining or stalking order.
18. Do you or anyone in your household have a serious health condition that
:
if 18 is yes
required medical care in the past 12 months (for example, diabetes,
____
arthritis, HIV/AIDS, stroke, cancer, serious asthma, etc.)?
19. Have you or anyone in your household ever been convicted of a felony?
:
if 19 is yes
(I
,
#20.)
F NO
SKIP TO
____
19a. Did the felony conviction occur in the past 12 months?
20. In the past 12 months have you or anyone in your household been
:
if 20 is yes
convicted of a misdemeanor?
____
21. Have you or anyone in your household ever been diagnosed with a
:
if 21 is yes
developmental or learning disability (such as a delay in language
____
development, short attention span (ADD or ADHD), mental retardation,
or autism, etc.)?
Page 5 of 7 – Prepared by Westat
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