Restorative Assessment Survey
Delco Youth Hub 
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How old are you?
Are you the head of household? 
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How many people currently live in your household (Including yourself)?
 Does anyone in your household have a physical or mental disability?
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What is the highest degree or level of school you have completed? If currently enrolled, mark the previous grade or highest degree received.

How many times has your family moved in the past year?
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 Many families have a number of strengths as well as challenges. From the statements listed below, please indicate how well each characteristic describes your family.

In my family, we talk about problems.

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When we argue, my family listens to "both sides of the story."

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In my family, we take time to listen to each other.

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My family pulls together when things are stressful.

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My family is able to solve our problems. 

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What are the things that make it difficult for you or other adults in your household to find and/or keep work? (check all that apply)

Please check off up to five topics with which you would like to have more assistance, and then put a star next to the topic most important to you.

I would like....

What social problem is the biggest threat to your community?

 What Type of Support Would Best Serve Your Community? (Mark all that apply)
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