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FPS # ___________________________
Last Name _______________________
Age _____________
1. Gave birth ___Yes ___ No ___ No information
2. Number of children gave birth to _____
3. Child(ren) adopted out at birth or early age ___All ___ At least one ___None
4. Age of children (who are not adopted out) at the time of Intake
(enter number of children beside appropriate age group)
_____ 5 or under
_____ 16 or under
_____ 17 and older
_____ no information
5. Prior to mother's incarceration, children lived with
(enter number of children beside appropriate living arrangement)
___ All grown up and live apart
___ Mother single
___ Mother and her partner/child's father
___ Father
___ Grandparent(s): ___maternal ___paternal
___ Mother's friend
___ All in care/adopted out
___ Relatives (father/mother's sister, uncles, etc.)
___ Foster care/CAS ward
___ Other (____________)
___ No information
6. During mother's incarceration, children are in care of:
(enter number of children beside appropriate living arrangement)
___ All grown up and live apart
___ Grandparent(s): ___maternal ___paternal
___ Father
___ Step-father
___ Foster care/CAS ward
___ Mother's friend
___ Relatives (father/mother's sister, uncles, etc.)
___ Other (____________)
___ No information
7. During incarceration mother:
___ has no contact with child(ren)
___ maintains contact (what kind? _________)
___ plans to apply for Private Family Visit
___ no information
1. Childhood/adolescence experiences:
___ States or describes growing up in an abusive, dysfunctional environment
___ States or describes growing up in a positive/supportive environment
___ States that she did not experience any kind of abuse
Conveys experiences of:
____ Physical abuse Abuser(s):
____ Mother
____ Father
____ Step parent
____ Foster parent
____ Sibling(s)
____ Relatives
____ Teacher(s)
____ Family friend(s)
____ Partner
____ Other
____ No information
____ Verbal/emotional abuse Abuser(s):
____ Father
____ Step parent
____ Foster parent
____ Sibling(s)
____ Relatives
____ Teacher(s)
____ Family friend(s)
____ Partner
____ Other
____ No information
____ Sexual abuse Abuser(s):
____ Mother
____ Father
____ Step parent
____ Foster parent
____ Sibling(s)
____ Relatives
____ Teacher(s)
____ Family friend(s)
____ Partner
____ Other
____ No information
_____ No information on childhood/adolescence experiences
2. Ran away from home before age 18
____ Yes _____ No ____ No information
3. Lived in foster home/was apprehended by social services as a child
____ Yes _____ No ____ No information
4. Adulthood experiences
____ Gives a general statement on having experienced abuse (unspecified experiences of abuse)
Abuser: ____ partner ____ other (_______)
_____ States that she did not experience any kind of abuse
Reports:
_____ Physical abuse
Abuser: ____ partner ____ other (_______)
____ Verbal/emotional abuse
Abuser: ____ partner ____ other (_______)
____ Sexual abuse
Abuser: ____ partner ____ other (_______)
Relationships qualified as:
___ All abusive ___ Some abusive ____ Positive ______ No information
_____ No reference to experiences of abuse in adulthood