Intake Questionnaire

You have been sent this link as part of your assessment process with The ACFB Fund. To ensure we capture as much information as possible, we have compiled a large list of questions in the survey below. Please do your best to answer the questions as best as possible.

For those questions that do not apply to you but are marked as required, please simply write “NA” or the like and move on.

Please give yourself 45-60+ minutes to complete this questionnaire. Responses are not saved until the entire form is completed.

Please enable JavaScript in your browser to complete this form.

Step 1 of 11

Name

First

Last

Tell us a bit more about what you were like in the early years? (Pre-3 years old)

Did you walk or talk early/late? Were you described by family members as a fussy baby? Did you have both parents in your life? Other significant loved ones?

Give us as full of a picture as you can.

Nominated Collateral Person #1

First

Last

This is someone who has known you since before age 12 but preferrably since pre-3. If you do not have someone to nominate, put your name in the box above.

You have the ability to nominate up to 2 people. We will contact your first nomination first and will only contact your second nomination should there be problems with the first.

Relation to you

At what age did you meet this person?

Their Email #1

If you do not have someone please put your email in this box.

Nominated Collateral Person #2

First

Last

Relation to you

At what age did you meet this person?

Their Email #2

If you do not have someone please put your email in this box.

Tell us a bit more about what you were like as a child?

Did you have friends? What was school like for you? Were you ever bullied? Any significant trauma (death, terrorism, medical, sexual, etc)? How did you get along with siblings, cousins, and other family members? Did you meet typical milestones such as making eye contact, pointing, or sharing interest in things?

Give us as full of a picture as you can.

Tell us a bit more about what you were like as a teen?

Did you have friends? What was school like for you? Were you ever bullied? Any significant trauma (death, terrorism, medical, sexual, etc)? Any difficulties with puberty or menstruation?

Give us as full of a picture as you can.

Tell us a bit more about what you are like as an adult? (If applicable)

How have you changed over the years? What symptoms are you noticing that bring you to this assessment? How is it affecting your day-to-day living? How is it affecting your relationships/friendships/people in your life?

Give us as full of a picture as you can.

Intake Questionnaire

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