Youth Link - Durham Digital Consulting

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YOUTH DEMOGRAPHIC INFO

Please complete the form below as accurately as possible.

Name

Age

Gender

Location

Date

Participant #

YOUTH PRE-ASSESSMENT

Impactful Issues

Please indicate in the order of priority, four (4) issues that are impacting your life.

# Issues Age

Issue No. 1

Issue No. 2

Issue No. 3

Issue No. 4

Stages of Change

	Haven't thought about it	Thinking about it	Starting to do something about it	Actively doing Something	Continuing
Issue No. 1	Haven't thought about itIssue No. 1 Haven't thought about it	Thinking about itIssue No. 1 Thinking about it	Starting to do something about itIssue No. 1 Starting to do something about it	Actively doing SomethingIssue No. 1 Actively doing Something	ContinuingIssue No. 1 Continuing
Issue No. 2	Haven't thought about itIssue No. 2 Haven't thought about it	Thinking about itIssue No. 2 Thinking about it	Starting to do something about itIssue No. 2 Starting to do something about it	Actively doing SomethingIssue No. 2 Actively doing Something	ContinuingIssue No. 2 Continuing
Issue No. 3	Haven't thought about itIssue No. 3 Haven't thought about it	Thinking about itIssue No. 3 Thinking about it	Starting to do something about itIssue No. 3 Starting to do something about it	Actively doing SomethingIssue No. 3 Actively doing Something	ContinuingIssue No. 3 Continuing
Issue No. 4	Haven't thought about itIssue No. 4 Haven't thought about it	Thinking about itIssue No. 4 Thinking about it	Starting to do something about itIssue No. 4 Starting to do something about it	Actively doing SomethingIssue No. 4 Actively doing Something	ContinuingIssue No. 4 Continuing

Select the current stage of change for each issue identified.

RISK FACTORS

In your own experience, how much are you at risk for each of the following categories below.

Individual Risks

Individual

	1 - Very Negative	2 - Negative	3 - Neutral	4 - Positive	5 - Very Positive
Physical Health	1 - Very NegativePhysical Health 1 - Very Negative	2 - NegativePhysical Health 2 - Negative	3 - NeutralPhysical Health 3 - Neutral	4 - PositivePhysical Health 4 - Positive	5 - Very PositivePhysical Health 5 - Very Positive
Sexual Health	1 - Very NegativeSexual Health 1 - Very Negative	2 - NegativeSexual Health 2 - Negative	3 - NeutralSexual Health 3 - Neutral	4 - PositiveSexual Health 4 - Positive	5 - Very PositiveSexual Health 5 - Very Positive
Mental/Emotional Health	1 - Very NegativeMental/Emotional Health 1 - Very Negative	2 - NegativeMental/Emotional Health 2 - Negative	3 - NeutralMental/Emotional Health 3 - Neutral	4 - PositiveMental/Emotional Health 4 - Positive	5 - Very PositiveMental/Emotional Health 5 - Very Positive
Life Skills eg. problem solving	1 - Very NegativeLife Skills eg. problem solving 1 - Very Negative	2 - NegativeLife Skills eg. problem solving 2 - Negative	3 - NeutralLife Skills eg. problem solving 3 - Neutral	4 - PositiveLife Skills eg. problem solving 4 - Positive	5 - Very PositiveLife Skills eg. problem solving 5 - Very Positive
Positive Attitude/Self image	1 - Very NegativePositive Attitude/Self image 1 - Very Negative	2 - NegativePositive Attitude/Self image 2 - Negative	3 - NeutralPositive Attitude/Self image 3 - Neutral	4 - PositivePositive Attitude/Self image 4 - Positive	5 - Very PositivePositive Attitude/Self image 5 - Very Positive

Relationship Risks

Relationships

	1 - Very Negative	2 - Negative	3 - Neutral	4 - Positive	5 - Very Positive
Family	1 - Very NegativeFamily 1 - Very Negative	2 - NegativeFamily 2 - Negative	3 - NeutralFamily 3 - Neutral	4 - PositiveFamily 4 - Positive	5 - Very PositiveFamily 5 - Very Positive
Role Models	1 - Very NegativeRole Models 1 - Very Negative	2 - NegativeRole Models 2 - Negative	3 - NeutralRole Models 3 - Neutral	4 - PositiveRole Models 4 - Positive	5 - Very PositiveRole Models 5 - Very Positive
Peer Pressure	1 - Very NegativePeer Pressure 1 - Very Negative	2 - NegativePeer Pressure 2 - Negative	3 - NeutralPeer Pressure 3 - Neutral	4 - PositivePeer Pressure 4 - Positive	5 - Very PositivePeer Pressure 5 - Very Positive
Friends	1 - Very NegativeFriends 1 - Very Negative	2 - NegativeFriends 2 - Negative	3 - NeutralFriends 3 - Neutral	4 - PositiveFriends 4 - Positive	5 - Very PositiveFriends 5 - Very Positive
Social skills eg. Interpersonal skills	1 - Very NegativeSocial skills eg. Interpersonal skills 1 - Very Negative	2 - NegativeSocial skills eg. Interpersonal skills 2 - Negative	3 - NeutralSocial skills eg. Interpersonal skills 3 - Neutral	4 - PositiveSocial skills eg. Interpersonal skills 4 - Positive	5 - Very PositiveSocial skills eg. Interpersonal skills 5 - Very Positive

Community Risks

Community

	1 - Very Negative	2 - Negative	3 - Neutral	4 - Positive	5 - Very Positive
Awareness of Needed Services	1 - Very NegativeAwareness of Needed Services 1 - Very Negative	2 - NegativeAwareness of Needed Services 2 - Negative	3 - NeutralAwareness of Needed Services 3 - Neutral	4 - PositiveAwareness of Needed Services 4 - Positive	5 - Very PositiveAwareness of Needed Services 5 - Very Positive
Ability to Access Needed Services	1 - Very NegativeAbility to Access Needed Services 1 - Very Negative	2 - NegativeAbility to Access Needed Services 2 - Negative	3 - NeutralAbility to Access Needed Services 3 - Neutral	4 - PositiveAbility to Access Needed Services 4 - Positive	5 - Very PositiveAbility to Access Needed Services 5 - Very Positive
Sense of Belonging to Community	1 - Very NegativeSense of Belonging to Community 1 - Very Negative	2 - NegativeSense of Belonging to Community 2 - Negative	3 - NeutralSense of Belonging to Community 3 - Neutral	4 - PositiveSense of Belonging to Community 4 - Positive	5 - Very PositiveSense of Belonging to Community 5 - Very Positive
Community safety	1 - Very NegativeCommunity safety 1 - Very Negative	2 - NegativeCommunity safety 2 - Negative	3 - NeutralCommunity safety 3 - Neutral	4 - PositiveCommunity safety 4 - Positive	5 - Very PositiveCommunity safety 5 - Very Positive
Community Support	1 - Very NegativeCommunity Support 1 - Very Negative	2 - NegativeCommunity Support 2 - Negative	3 - NeutralCommunity Support 3 - Neutral	4 - PositiveCommunity Support 4 - Positive	5 - Very PositiveCommunity Support 5 - Very Positive
Gun Violence	1 - Very NegativeGun Violence 1 - Very Negative	2 - NegativeGun Violence 2 - Negative	3 - NeutralGun Violence 3 - Neutral	4 - PositiveGun Violence 4 - Positive	5 - Very PositiveGun Violence 5 - Very Positive
Other Forms of Violence	1 - Very NegativeOther Forms of Violence 1 - Very Negative	2 - NegativeOther Forms of Violence 2 - Negative	3 - NeutralOther Forms of Violence 3 - Neutral	4 - PositiveOther Forms of Violence 4 - Positive	5 - Very PositiveOther Forms of Violence 5 - Very Positive
At-risk of Substance Addition	1 - Very NegativeAt-risk of Substance Addition 1 - Very Negative	2 - NegativeAt-risk of Substance Addition 2 - Negative	3 - NeutralAt-risk of Substance Addition 3 - Neutral	4 - PositiveAt-risk of Substance Addition 4 - Positive	5 - Very PositiveAt-risk of Substance Addition 5 - Very Positive
Home Safety	1 - Very NegativeHome Safety 1 - Very Negative	2 - NegativeHome Safety 2 - Negative	3 - NeutralHome Safety 3 - Neutral	4 - PositiveHome Safety 4 - Positive	5 - Very PositiveHome Safety 5 - Very Positive

Additional Notes

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