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Safety Questionnaire Self-Assessment

Time to put your thinking cap on! 
🧢 
The purpose of this questionnaire is to provide information about the   personal and unique safety concerns within your post-adoptive household regarding your own safety as well as the safety of others in your home. 

This questionnaire will function as your safety self-assessment so consider each question carefully; the more thorough your answers the better. The more accurately I can understand your concerns, the better and the more specific, strategic and thorough I can be in the safety plan audit. 

I also encourage you to be succinct in your answers so that they do not become too cumbersome or trail off unnecessarily.

I recognize that it can elicit emotional responses that can possibly be intense. Take breaks as needed and don’t rush it. But do not let yourself get too bogged down in the nitty gritty details either. Just move through each question with your best “now” answer.

While I make every effort to keep your information private and secure, please do not share any sensitive information

Below is a comprehensive list of self-assessment questions to help identify potential safety risks:

My aim in this audit is to highlight any gaps in your safety planning so that you can focus on getting those filled, prioritizing the urgent safety concerns while also recognizing your short-term & longer-term safety concerns.

- Dawn
 
Do you have a written safety plan?*
What is the top reason you think a safety plan is currently needed? *
This set of questions is related to physical safety concerns. Has your adopted child exhibited any physically aggressive behaviors, such as hitting, biting, or throwing objects?*
If yes, are there any specific triggers that seem to lead to these aggressive outbursts?
How often do these incidents occur and in what settings (home, school, public, etc.)?
Have other family members or pets been harmed during these episodes?
Emotional and Psychological Safety questions: Do you notice any patterns of verbal aggression, such as yelling, threatening, or bullying behaviors?*
If yes, how do these behaviors impact the emotional well-being of other family members and yourself?
Are there signs of anxiety, depression, or other mental health challenges in any family member as a result of the child's behavior?
This next set of questions pertain to Social and Relational Safety: Does your adopted child exhibit behaviors that cause division within the family or affect relationships with friends and extended family members?*
Are siblings affected by these behaviors, and if so, how? Are there changes in their academic performance, social interactions, or emotional health
Have you or any family members felt isolated or withdrawn due to the challenges at home?
The next set of questions relates to Financial and Property Concerns: Have there been any incidents of property damage caused by the adopted child? If so, what was damaged and to what extent?
If yes - Are there costs associated with repairs, replacements, or additional security measures that have impacted your financial stability?
Have medical or therapeutic expenses related to addressing these behaviors placed a strain on your family budget?
Spiritual and faith impact questions: How has this journey affected your faith and relationship with God?
Are there ways your church community or faith can support you in this season?
Have you been able to find spiritual counseling or support groups through your church to help navigate these challenges?
Developmental and Educational Concerns: How is your child performing academically? Are there any concerns raised by teachers or school counselors?
Have you noticed any developmental delays or regressions since these behaviors began?
Are there specific therapeutic or educational interventions currently in place? If so, have they been effective?
Personal Reflection questions: How are you coping personally with these challenges? Do you have a self-care routine or support system in place?
Have you experienced burnout or compassion fatigue (burnout/secondary trauma)?
What are your current needs or the needs of your family that you feel are not being met?













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