Entry Survey

First name

Last name

I feel my communication with my family is

I DON'T get along with my family and have a lot of conflict. This has a PROFOUND NEGATIVE impact on my daily life

I have SOME DIFFICULTY getting along with my family. This has a NEGATIVE impact on my daily life

SOMETIMES I don't get along with or communicate well with my family but this is IMPROVING

I GET ALONG and communicate well with my family. I have difficulties ONLY OCCASIONALLY

I GET ALONG and communicate very well with my family and this has POSITIVE IMPACTS on my daily life

How I feel about engaging with sevices

I have A LOT OF DIFFICULTY engaging and working with services to help me improve my cirucmstances

I have SOME DIFFICULTY engaging and working with services to help me improve my circumstances

I OCCASSIONALLY have difficulty engaging and working with services to help me improve my circumstances

I SELDOM have difficulty engaging and working with services to help me improve my circumstances

it is EASY to work with services to help me improve my circumstances. I RARELY have difficulties

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