Interview date:
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Today M-D-Y
Sanna Schneeberger Steven James Courtney Moore Janee Henderson Jomella Watson-Thompson Other Monica Mendez Sara Obermeier
If you selected other, please specify:
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Please include your first and last name.
Who is the person being interviewed?
Who is present for this interview?
Number of youth from this family involved in ThrYve or ThrYve Prep.
First name of youth:
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Please provide youth's first and last name
Date of birth for youth:
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Today M-D-Y
Age of youth:
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Gender of youth:
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Male Female Transgender Other
Below is a system for making a unique ID for the youth you are interviewing. In no way does this allow anyone to trace responses back to the youth.
Please spell your first name.
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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
Please spell your mother's first name
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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
If youth does not know mother's first name, please select the letter "X"
Please spell your middle name
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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
If youth does not have a middle name, please select the letter "X".
Please spell your last name.
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A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
What month were you born?
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A D F J M N O S X
If youth does not know birth month, please select the letter "X".
Study ID: ______ ______ ______ ______ ______
Do not need to complete.
Corrected ID (Staff Use ONLY)
ThrYve Staff: Please use the following questions as a guide for interviewing youth about the risk and resilience factors present in their lives. You do not have to ask all the questions but try to ask as many as possible, depending on the flow of the conversation. Please take only short notes. There is no need to write down what the participant says word for word.
I am going to ask you some questions about your home situation and family life.
Who are you living with now? How long have you been there?
If youth is not living with his or her parents, ask about the history of the current living arrangements
Do you have any brothers or sisters? How do you get along with them? Is there much fighting at home?
Do your mom and dad/caretaker(s) work? What do they do? Is the family income adequate?
Is there anything else you would like to tell me about your home life?
Are you in school or enrolled for school right now?
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Yes
No
I am going to ask you some questions about your school.
Where do you go to school (in the fall)?
How well are you doing in your schoolwork? Have you been doing better (or worse) recently?
What subjects do you like; which ones do you not like?
Do you have an IEP or receive special services? Have you ever been assessed by a psychologist or special education teacher? Do you know the results?
Have you had any trouble in school over the past year or so? Have you been suspended or expelled? Have your parents been called to the school because of problems?
How well have you been getting along with your teachers and with other students?
Do you skip school? Why or why not?
Are you proud to be a member of your school? Why/why not?
Are you usually on time to school? Do you want to go to school? Do you plan to stay in school and graduate? Do you think education is important?
Are you working now?
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Yes
No
Is your job part-time or full-time?
How well do you like your job? How do you get along with your supervisors/managers?
Are you looking for work? Why or why not? What efforts have you made to find work?
What are the kinds of things that really interest you (sports, hobbies, etc.)? Are there new things you would like to learn?
Are you involved in any clubs, organizations, or sports teams in community (for example, Boys and Girls Club)? Do you enjoy these activities? Would you like to be more involved in these activities?
Are you easily frustrated or are you a fairly easygoing person?
Do you have trouble concentrating? Have you ever been told that you have a problem with concentration or with attention?
Do you feel that you are good at planning things or do you tend to do things on the spur-of-the moment?
How do you usually feel when you do something wrong? Do you feel bad when you hurt someone?
Do you ever feel very anxious or depressed? How often do you have these feelings?
How do you handle or cope with stress? What stresses you?
When you do something hurtful to your peers or teachers, what do you do afterward?
Do you think you should obey rules? At home? In the community? In school?
What do you think about efforts to address violence? How do you think ThrYve can help you?
I would like to ask a few questions about your friends-the people you hang out with.
Who are your closest friends at present?
Are you involved in a relationship at the moment? Can you tell me about the person with whom you are involved?
Have any of your friends been involved with the police? Have any been arrested?
Are you a member of a gang, clique, or street organization? Do you know gang members?
Can you think of any adults who encourage you, make you feel accepted, give you affection, or tell you you are good at things? If so, who? How do you know them (e.g., teacher, parent, etc.)?
Do you feel like you fit in? Do you feel like other kids your age accept you?
Do you have any adults you look up to? Tell me about them. Do they provide you with support when you need it? Do they set a positive example for you? How?
Do you feel you are healthy? Are you able to address your health needs?
I would like to ask some questions about alcohol and drugs.
Do your parents worry about whether you use drugs or alcohol? Why/why not?
What are areas you'd like ThrYve to support (or provide referrals for you)?
What are the top three goal areas you would like to support with ThrYve?
ThrYve offers services but also works to broker partnerships and opportunities. Is your youth interested in any of the following (reference the summer program menu if you have additional questions):
Is there anything else you would like to discuss with me? Are there any questions you would like to ask?
How do you feel you get along with your mother/father/caretaker(s)? How would you describe your relationship with them/him/her?
How tough are your parents/caretakers about enforcing the rules?
Are there a lot of rules at home? Do you think they are fair?
What do your parents/caretakers do when you break the rules? How do they discipline you?
How do your mom and dad (or caretaker and their partner) get along?
How do you feel about yourself? Do you generally feel good about things? Are you sometimes disappointed in yourself?
Do you get angry about things? What kinds of things make you especially angry?
How do you usually react when you are angry? Do you often get into fights?
Is anything worrying you at the moment about your friends, your school, or family?
Do your friends use drugs around you?
Do your friends drink alcohol around you?
Have you had any past problems with drugs or alcohol use? What about current problems?
Would you like to get some help to stop drinking or using drugs?
Did you ever see physical violence between your parents or between your parents and siblings, or other adults in your home? How often? Is there anything you want to share?
Did you feel safe in your house when you were younger (under aged 12)? Did you feel you had enough food, shelter, clothing? Did anyone tell you that you might not? Did you go to the doctor when you needed to? Did your parents supervise you?
Do you ever feel like you are in so much pain, numbness, or anger that you harm yourself to feel better? Have you ever thought about suicide? Have you ever tried to commit suicide?
Parent - What is your first, middle and last name?
Parent - What is your Social Security number?
Parent - What is your date of birth?
Parent - What is your home phone number?
Parent - What is your cell phone number?
Parent - What is your email?
Parent - Do you prefer to be contacted by email or text?
Email
Text
Parent - What is your street address (e.g., 123 Main St).
Parent - What city do you live in?
Parent - What is your zip code?
Parent - What county do you live in?
Youth - What is your Date of Birth?
Youth - What is your Social Security number?
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Youth - What is your cell phone number?
Youth - What is your email address?
Parent - Card Token Number: Please indicate the token number.
Parent - Signature: Please provide your signature that indicates a debit card was provided to you.
Youth - Card Token Number: Please indicate the token number.
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Youth - Card Letter ID field: Enter the 16, 17, 18th number of the letter and number ID at the top line on envelope.
Youth - Signature: Please provide your signature that indicates a debit card was provided to you.
Thank you. That's the end of our interview.
ThrYve Staff: Would you like to continue to the risk and resilience rating form?
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Yes
No
If you have not had the chance to corroborate youth responses with multiple sources of information (e.g. parents, schools, etc.), choose "NO". You can return to the rating form later.
Are you completing this rating form on the same day you completed the youth interview?
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Yes
No
Is the same person who conducted the youth interview also completing this rating form?
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Yes
No
Today's date:
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Today M-D-Y
Your name:
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Janee Henderson Sanna Schneeberger Steven James Other
If you selected other, please specify:
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Please include your first and last name.
We recommend using information obtained from multiple sources to rate items on youth risk and resilience. Which of the following sources did you use to get corroborating evidence for the ratings you are about to submit?
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Choose as many as apply.
Prosocial Involvement
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Present - Involved in prosocial activities/peer groups
Absent - Little/no involvement in prosocial activities/peer groups
Critical item
Strong social support
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Present - strong social supports
Absent - no strong social supports
Critical item
Strong attachment and bonds
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Present - strong attachment or bond with 1 or more prosocial adult(s)
Absent - no attachment or bond with any prosocial adults
Critical item
Positive attitude toward intervention and authority
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Present - positive attitude toward remediation and authority
Absent - not a positive attitude toward remediation and authority
Critical item
Strong commitment to school
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Present - exhibits high levels of interest, involvement and motivation in school
Absent - does not exhibit high levels of interest, involvement and motivation in school
Critical item
Resilient personality traits
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Present - exhibits positive and resilient personality characteristics
Absent - does not exhibit resilient personality traits
Critical item
Peer Delinquency
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Low - does not associate with delinquent peers
Moderate - Occasionally associates with delinquent peers
High - Frequently associates with delinquent peers
Critical item
Peer rejection
* must provide value
Low - no peer rejection
Moderate - moderate peer rejection or significant past rejection
High - significant peer rejection
Critical item
Low - mild stress, no significant losses, with average coping ability
Moderate - moderate stress or loss, with adequate coping ability
High - moderate to significant stress or loss, with poor coping ability
Critical item
Low - consistent and appropriate parental management
Moderate - somewhat inconsistent parental management
High - extremely inconsistent or overly strict/permissive parental management
Critical item
Lack of personal/social support
* must provide value
Low - multiple sources of emotional support and guidance
Moderate - inconsistent or unreliable emotional support or guidance
High - few or no sources of emotional support and guidance
Critical item
Negative Attitudes
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Low - attitudes do not support crime or violence
Moderate - some attitudes supportive of crime or violence
High - attitudes condone crime and/or violence
Critical item
Risk taking/impulsivity
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Low - exhibits no problems with risk taking/impulsivity
Moderate - exhibits minor risk taking/impulsivity
High - exhibits significant risk taking/impulsivity
Critical item
Substance-use difficulties
Low - no current or past problems with drug/alcohol use
Moderate - no current significant problems but has significant past issues
High - serious current difficulties related to alcohol and/or drugs
Critical item
Anger management problems
Low - age appropriate ability to manage expressions of anger
Moderate - moderate difficulty controlling expressions of anger
High - significant difficulty controlling expressions of anger
Critical item
Low empathy/remorse
* must provide value
Low - age-appropriate capacity for remorse/empathy
Moderate - moderate impairment in age-appropriate capacity for remorse/empathy
High - significant impairment in age-appropriate capacity for remorse/empathy
Critical item
Attention deficit/hyperactivity difficulties
* must provide value
Low - no difficulties with restlessness, hyperactivity, or concentration
Moderate - moderate difficulties with restlessness, hyperactivity, or concentration
High - serious difficulties with restlessness, hyperactivity, or concentration
Critical item
Low - positive attitude toward intervention/supervision
Moderate - occasional negative attitude toward intervention/treatment
High - frequent negative attitude toward intervention/treatment
Critical item
Low interest/commitment to school
* must provide value
Low - average interest/commitment to school
Moderate - low interest/commitment but presently attends and completes school work
High - low interest/commitment; often truant, late, does not complete school work
Critical item
History of violence
* must provide value
Low - no acts of violence
Moderate - 1 to 2 acts of violence
High - more than 3 acts of violence
Critical item
History of Nonviolent Offending
* must provide value
Low - no prior nonviolent offending
Moderate - less than 5 acts of nonviolent offending
High - 5 prior acts of nonviolent offending
Critical item
Early Initiation of Violence
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Low - No known violent acts before age 14
Moderate - First known violent act between ages 11 and 13
High - First known violent act prior to age 11
Critical item
Has youth ever been charged with a violent or non-violent offense?
* must provide value
Yes
No
What type of offense was youth charged with?
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Non-violent offense
Violent offense
Both violent and non-violent offense
Past Supervision/Intervention Failures
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Low - Complied with all court orders and treatment
Moderate - Failed to comply w/ court orders and/or treatment < 3 times
High - Failed 3 times to comply w/ court orders or treatment
Critical item
History of Self-Harm or Suicide Attempts
* must provide value
Low - No history of self-harm or suicide attempts
Moderate - History of self-harm or suicidal gestures w/ no clear suicidal intent
High - History of serious self-harm or suicide attempts
Critical item
Exposure to Violence in the Home
* must provide value
Low - Has not witnessed violence in the home
Moderate - Witnessed occasional physical aggression and/or 1 act of serious forms of violence in the home
High - Witnessed chronic physical aggression or serious forms of violence in the home
Critical item
Childhood History of Maltreatment
* must provide value
Low - No physical abuse or neglect
Moderate - Infrequent or less serious physical abuse or neglect
High -Chronic or severe physical abuse or neglect
Critical item
Parental/Caregiver Criminality
* must provide value
Low - No parental/caregiver history of criminal behavior as an adult
Moderate - Parental/caregiver history of occasional (< 5) minor criminal behavior as an adult
High - Parental/caregiver history of frequent ( 5) minor or any serious criminal behavior as an adult
Critical item
Early Caregiver Disruption
* must provide value
Low - Continuity of care occurred during childhood
Moderate - Some discontinuity of care occurred during childhood
High - Significant discontinuity of care occurred during childhood (>1 year)
Critical item
Poor School Achievement
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Low - No significant difficulties in school achievement
Moderate - Some difficulties in school achievement
High - Significant difficulties in school achievement
Critical item
If signature was not captured when survey originally completed, upload Parent signature here.
If signature was not captured when survey originally completed, upload Youth signature here
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