Family Vulnerability Index (VI)

Family Vulnerability Index

Introduction

Different housing programs in Chicago offer different types of supports. This screening will help determine which housing program will best fit your needs. I will ask questions about things like your health experiences, any children you may have, and any involvement in foster care. Some of the questions are personal in nature and may be difficult to answer. If you do not feel comfortable answering a question, please just ask me to skip it. The information you provide will be used to assess eligibility for housing programs and level of service intervention required.

If any of the questions are confusing or you don’t know how to answer, feel free to ask and I will be happy to clarify for you.
I know that we have only been talking for a short time and some answers you may not want to share with someone you just met. It’s up to you how honest you are in this survey, but the more truthful you are, the better we can match you to the right program and support you in finding stable housing. If you need a break at any point, please feel free to let me know. 

PLEASE DO NOT PRINT THIS PAGE.  IF YOU NEED A PRINTED COPY, PLEASE PRINT THE ATTACHED PDF.

 Disability
1. This question asks about a disabling condition, which means any condition that limits your ability to work or perform daily activities. Some examples include a substance abuse disorder, serious mental illness, developmental disability, or chronic physical illness. Have you been diagnosed with a disabling condition?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

1a. If so, would you like support accessing documentation from a doctor or other medical professional about the disabling condition?
Yes, I would like support accessing documentation ___
No ___

Children
2. Do you have any children under age 18 who are currently not living with you?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

2a. If yes, where are these children staying?
-Foster care ____
-Group home____
-With family____
-With friends____
-Other (please specify): ______________________________________________

2b. if yes, are they living apart from you because you are experiencing homelessness (i.e. you couldn’t bring them to the shelter)?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

Child Welfare
2c. Have you ever had an open case with the child welfare system for any of your children (including children who are living with you and those who are not)?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

2d. Do you currently have an open case with the child welfare system?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

2e. Are you currently receiving any services as a result of a child abuse/neglect investigation?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

2f. Have you ever had one of your children placed in foster or adoptive care?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

3. At what age did you have your first child? _____

Healthcare
4. Have you received treatment for a mental health issues in the 25 months?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

4a. Have you ever been diagnosed with a mental health condition?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

4b. Have you ever been hospitalized for mental health reasons?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

4c. Observer response: Skilled Assessor observed mental health condition?
Yes ___
No ___

5. In the past year, has anyone in your family repeatedly criticized you for using alcohol or drugs? For example, does someone close to you think your intake is too high or suggested you reduce your use?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

5a. Have you received treatment services for alcohol and/or drug use in the last 12 months?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

6. Do you have a medical condition that makes it difficult to carry out the activities of daily living?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

7a. Do any of your children have any serious medical conditions that make it difficult for you to carry out the activities of daily life?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

7b. Do any of your children have any serious behavioral health conditions that make it difficult for you to carry out the activities of daily life?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

7c. If yes, how many of your children have a serious medical condition OR behavioral health condition that make it difficult for you to carry out the activities of daily life? _____

8. Are you or any of your children impacted by HIV or AIDS?
Yes ___
No ___
Client doesn’t know ___
Client refused ___
Data not collected ___

Life Struggles
9. As a child, were any of the following statements true for you?
My parent/caregiver abused drugs or alcohol _____
My parent/caregiver died or otherwise abandoned me _____
I was sexually abused _____
I was physical or verbal abused or neglected ____
I spent time living in foster care or in another setting without my primary caregiver or parent ____
I experienced homelessness ____
I moved frequently ____
I was told I have a learning disability or was offered a special service in school ____
None of the above ____

9a. If yes, how much do these experiences negatively affect your life?
A lot ____
A little ____
Not at all ____

10. As an adult, are any of the following statements true for you?
I have a criminal history ____
I have been a survivor of relationship violence ____
I have been a survivor or rape ____
I have been physically assaulted ____
I have tried to commit suicide ____
None of the above are true for me ____

10a. If yes, how much do these experiences negatively affect your life?
A lot ____
A little ____
Not at all ____

Thank you for answering the questions on this part of the survey. I appreciate you being willing to share that information with me.