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Environmental Screening Questionnaire

RESEARCH EDITION

Caregiver's name: Jane Smith
Date: July 22, 2020
John Smith

INSTRUCTIONS:

Check YES or NO in the box that best fits your current situation. Check CONCERN if this is a problem for you or your family.

A. Education and Employment YES NO CONCERN
1. Are you a high school or GED graduate? ☑Z ☐X ☐V
2. Do language problems get in the way of your finding or keeping a job? ☐X ☑Z ☐V
3. Do you have problems with reading or writing? ☐X ☑Z ☐V
4. Are you employed or enrolled in classes or job training? ☐Z ☑X ☑V
5. Are you employed at the level you would like to be? ☐Z ☑X ☐V
If you checked CONCERN, what kind of help do you need? I could use help finding job classes or training
B. Housing YES NO CONCERN
1. Do you consider yourself homeless? (Examples include living in a shelter or car, or camping because you don't have a home or apartment.) ☐X ☑Z ☐V
2. Do you need to live with friends or family not by choice? (For example, you moved in with family because you can't afford housing.) ☑X ☐Z ☐V
3. Have you moved three or more times in the past year? ☐X ☑Z ☐V
4. Is your housing in below-average condition? (For example, you have no hot or cold running water, a leaky roof, or an outdoor toilet.) ☐X ☑Z ☐V
5. Have you or your child/children witnessed violence in your home or neighborhood? ☐X ☑Z ☐V
If you checked CONCERN, what kind of help do you need?
C. Child and Family Health YES NO CONCERN
1. Do you or does anyone in your home have major health problems? (Major means the problem is chronic and affects everyday life.) ☐X ☑Z ☐V
2. Do you and your family members have health insurance or access to regular medical and dental care? ☑Z ☐X ☐V
3. Does anyone in your home have alcohol or drug problems? ☐X ☑Z ☐V
4. Does anyone in your home have problems with depression, anger, or anxiety? ☐X ☑Z ☐V
5. Do you have a child with a learning or behavior problem? ☐X ☑Z ☐V
If you checked CONCERN, what kind of help do you need?
D. Economics and Finances YES NO CONCERN
1. Do you worry about having enough food for your family? ☑X ☐Z ☐V
2. Does your income cover your monthly expenses? ☑Z ☐X ☐V
3. Do you currently use support programs such as WIC, food stamps (SNAP), or Medicaid? ☑X ☐Z ☐V
4. Do you have credit problems? ☐X ☑Z ☐V
5. Do you have access to a phone when you need to make calls? ☑Z ☐X ☐V
If you checked CONCERN, what kind of help do you need?
E. Family Life YES NO CONCERN
1. Do you have a spouse/partner who lives with you most of the time? ☑Z ☐X ☐V
2. Do you have frequent spouse/partner conflicts? ☐X ☑Z ☐V
3. Are you in a relationship in which you have been physically hurt, felt threatened, or been controlled by someone else? ☐X ☑Z ☐V
4. Do you have child care that meets your family's needs? ☑Z ☐X ☐V
5. Are you able to read, play, or sing with your child/children several times per week? ☑Z ☐X ☐V
If you checked CONCERN, what kind of help do you need?
F. Community YES NO CONCERN
1. Does your family join in community activities? (Examples include going to the library, playing sports, going to church, or attending other community events.) ☑Z ☐X ☐V
2. Do you have people to talk to about your problems? ☑Z ☐X ☐V
3. Does your child/do your children get along well with other children? ☑Z ☐X ☐V
4. Do you have friends or family who can help when you need it? ☑Z ☐X ☐V
5. Do you have regular transportation? (Examples include access to a car, bus, train, or subway.) ☑Z ☐X ☐V
If you checked CONCERN, what kind of help do you need?

Referral Summary

Child's/children's name(s): John Smith
Caregiver's name: Jane Smith
Date: July 22, 2020
Person completing the form: Danielle Whitfield
Title: Family Services Specialist
Rescreen Date: November 1, 2020

Use this form to summarize ESQ results and decision-making regarding referrals and follow-up action based upon ESQ results. See ESQ™ Guide for further information.
• Score: Record area scores from ESQ. Add area scores for the overall total. Follow up is recommended for any parent concern and for scores of 30 or higher in any area.
• Resource Need: Review suggestions for resources in each ESQ area. Describe family requests and severity of need (significant or moderate). Indicate relevant resources and appropriate local agencies to assist with family needs.
• Action Taken: Describe action taken (contact information for referral agency, application, brochure, etc.). Indicate “No action taken” if family does not indicate a need for help.

ESQ AREA SCORE RESOURCE NEED ACTION TAKEN
A. Education and Employment 25 GED classes ESL classes College entrance Financial aid Job training Credit counseling Other: Provided a list of job training classes in the area and will help coordinate attendance
B. Housing 10 Public housing Homeless shelter Other:
C. Child and Family Health 0 Physical health Mental health Addiction Dental Insurance Child behavior Other:
D. Economics and Finances 20 Food pantry SNAP (food stamps) WIC program TANF Credit counseling Other:
E. Family Life 0 Couples counseling Domestic violence Respite care Child care Books for child Other:
F. Community 0 Specify available resources (faith-based, sports, camp, arts, community garden, library, parenting group, play group, public transportation):
Overall Total 55

Environmental Screening Questionnaire (ESQ™), Research Edition, Squires & Bricker, with assistance from Waddell, Funk, & Moxley-South.
©2020 Paul H. Brookes Publishing Co., Inc. All rights reserved. ESQ™ is a trademark of Paul H. Brookes Publishing Co., Inc.