# 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? | ☐X | ☑Z | ☐V |
| 2. Do you need to live with friends or family not by choice? | ☑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? | ☐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? | ☐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? | ☑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? | ☑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 on ESQ results.**

- **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.