Youth Introductory Questionnaire
The purpose of this questionnaire is to help resource parents get to know you as an individual from your perspective about yourself. It's an additional resource separate from the official documents that follow you as you transition into a more permanent setting. The questionnaire gives a potential resource family an idea of who and where you are currently in your transition. It can also help you begin a conversation when meeting with a new resource family. The PA Youth Advisory Board encourages all youth to complete the questionnaire with individuals from your support team to assist you in navigating the questionnaire.
Please complete the questions in accordance with your comfort level.
None of the fields in the questionnaire are mandatory.
About Me
My name is:
My preferred pronouns are:
E/Em/Eir
He/Him/His
She/Her/Hers
They/Them/Theirs
Xe/Xem/Xyrs
Ze/Hir/Hirs
Decline to answer
My email address is:
Would you like anyone else to receive a copy of these responses via email? If so, please provide that email address:
Age:
-- Select --
14
15
16
17
18
19
20
21
Grade:
-- Select --
8
9
10
11
12
Not applicable
Post-secondary education level:
-- Select --
Trade school
College
My religious preference is:
I practice my religion by:
What is your current gender identity (check all that apply)?
Agender
Female/Woman
Gender Fluid
Gender Non-Conforming
Genderqueer
Intergender
Intersex
Male/Man
Nonbinary
Other
Trans Man/Male
Trans Woman/Female
Transgender
None of these full describe me right now
Decline to answer
My sexual orientation is:
Living Environment
The environment I would be most comfortable living in would be:
My ideal preference for a resource home would include:
Some of the things to be aware of about my health are (i.e. physical, mental, emotional, social, etc.):
My ideal living space includes:
One can respect or maintain my privacy by:
Overall my physical health is:
Ways you can help me improve my mental and physical health include:
Overall my mental health is:
Some additional things you should know about me include (e.g. favorite foods, employment status/ambitions, friends, relationships with family, music taste, clothing style):
Support and Communication
I communicate best when:
I struggle to communicate when:
Communicate with me by:
Some of the things I am comfortable talking about include:
Some of the things I am hesitant to discuss include:
These are things that make me feel safe and secure:
The best way to support me during difficult times is:
A healthy relationship is one that:
Coping
I best feel emotionally supported by/when:
Some of the coping skills I practice are:
Please be patient as I develop trust. Some of the ways I develop trust are:
Some of my personal needs are:
Taking space is very important to me. I need space from others when:
Having space for me may include:
I have personal connections:
-- Select --
Yes
No
I am interested in developing personal/permanent connections:
-- Select --
Yes
No
Maybe
My personal connections consist of (birth family, coaches, siblings, mentors, members of my community, etc.):
These connections are important to me because:
Goals and Expectations
My permanency goals are:
I could use support in these areas:
These are some of things I can do on my own:
To me my future looks like:
Some expectations I have for myself are:
I believe I should be accountable/responsible for:
My long term career goals include:
Hobbies
A few things I like to do in my free time include:
Things that give me a sense of feeling normal include:
Some of my talents/interests include:
I am interested in exploring:
These are the things I need in order to enjoy some of my hobbies: