Volunteer Assessment All Family Beacon volunteers must complete this assessment. Please identify the appropriate role(s) for which you have applied. Beacon HomeHome CoachClient Coach Volunteer 1: Last Name, First Name Why do you want to volunteer with Family Beacon? Family History: Which has occurred in your family of origin? Domestic ViolenceChild Abuse/NeglectDivorceMental IllnessSubstance UseAbuseTraumatic Event(s) Please elaborate on any of the above: Childhood: discuss upbringing, parental/sibling relationships and family rules. Which of the following forms of discipline occurred in your family of origin: Time OutsSpankingLoss of PrivilegesGroundingOther Other Was discipline excessive? YesNo If yes, please explain: Volunteer 2: Last Name, First Name Why do you want to volunteer with Family Beacon? Family History: Which has occurred in your family of origin? Domestic ViolenceChild Abuse/NeglectDivorceMental IllnessSubstance UseAbuseTraumatic Event(s) Please elaborate on any of the above: Childhood: discuss upbringing, parental/sibling relationships and family rules. Which of the following forms of discipline occurred in your family of origin: Time OutsSpankingLoss of PrivilegesGroundingOther Other Was discipline excessive? YesNo If yes, please explain: Marriage Previous Marriage(s) (if applicable) Husband: YesNo Wife: YesNo Current Marriage (if applicable) Years Married: Any periods of separation? YesNo Strengths of Marriage: Current Marriage (if applicable) Weaknesses of Marriage: Values & Beliefs What is important to/in your family? Please describe your involvement in your church. Other Issues Volunteer 1: Have you ever been convicted of child abuse/neglect? YesNo Have you ever been arrested? YesNo Have you ever been convicted of a felony? YesNo Have you ever been involved in a domestic violence incident? YesNo Have you ever had a substance use or abuse or alcohol problem? YesNo Have you ever had mental health problems? YesNo Do you have health problems that impact your care giving role? YesNo Do you or anyone in your household smoke? YesNo Please elaborate on any yes answers: Volunteer 2: (if applicable) Have you ever been convicted of child abuse/neglect? YesNo Have you ever been arrested? YesNo Have you ever been convicted of a felony? YesNo Have you ever been involved in a domestic violence incident? YesNo Have you ever had a substance use or abuse or alcohol problem? YesNo Have you ever had mental health problems? YesNo Do you have health problems that impact your care giving role? YesNo Do you or anyone in your household smoke? YesNo Please elaborate on any yes answers: Are you willing to respect and help preserve the child’s culture and heritage while in your home? YesNo Are there firearms or weapons in the home? YesNo If yes, where are they stored? Are there pets in the home? YesNo If yes, please describe the number and type: Are the pets friendly to children? YesNo Are cleaning supplies and chemicals out of reach and secured? YesNo Are smoke detectors in operating order? YesNo Terms of Acceptance and Signature Volunteer 1: I attest that the aforementioned information is accurate and complete to the best of my knowledge. I, the applicant to be a Beacon Home, Beacon Coach, or Client Coach warrant the truthfulness of the information provided in this application. Signature Date (MM/DD/YYYY) Volunteer 2: I attest that the aforementioned information is accurate and complete to the best of my knowledge. I, the applicant to be a Beacon Home, Beacon Coach, or Client Coach warrant the truthfulness of the information provided in this application. Signature Date (MM/DD/YYYY) Δ