Wisconsin Family Quality of Life Index (F-QLI) Provider Questionnaire

Wisconsin Family Quality of Life Index (F-QLI) Provider Questionnaire
Family Quality of Life Index (F-QLI)
Marion A. Becker‚ Bret R. Shaw‚ Lisa M. Reib (1996)
 
The Family Quality of Life Provider Questionnaire
 
It’s not complete instrument: please see source.
BACKGROUND INFORMATION
·         Name and Date of birth (members of family)
·         How adequate is this family’s housing? (Check one)
·         What type of housing subsidy does this family receive: ………‚ No subsidy
·         How many times has this family moved in the last year: ……..
·         During the past four weeks‚ would you say that this client’s family life has been: Poor‚ Fair‚ Good‚ Very Good‚ Excellent
·         During the past four weeks this client has been spending …: (Check one): …
·         Is this client engaged in family activities? (Choose one) …
·         Does this family attend any social activities (e.g. church‚ club or interest group)? Frequently‚ Occasionally‚ Rarely‚ Never
·         Does this family generally make and keep up friendships? (Check one): …
·         How would you describe the quality of this family’s relationship with each other? Poor‚ Fair‚ Good‚ Very good‚ Excellent
·         How does this family feel about the money they have? Very dissatisfied‚ Moderately dissatisfied‚ A little dissatisfied‚ Neither satisfied nor dissatisfied‚ A little satisfied‚ Moderately satisfied‚ Very satisfied
·         How important to this family is money? Not at all important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important
·         How often does lack of money keep this family from doing what they want to do? Never‚ Sometimes‚ Frequently‚ Almost always
HEALTH AND WELL-BEING
·         In general‚ this family is able to accomplish the things that they need to do. Strongly agree‚ Agree‚ Disagree‚ Strongly disagree
·         In general‚ this family is able to cope with conflict and stress. (Check one): …
ALCOHOL & OTHER DRUGS
·         Does any member of this family use alcohol or other drugs? Not at all (skip next question)‚ Rarely‚ Occasionally‚ Often
·         Who in the family uses drugs? Please specify:
·         To what extent does this use of alcohol or other drug use concern you? Not at all‚ Slightly‚ Moderately‚ A lot
SUBSTANCE USE
Please indicate the extent of your client’s substance use and the individual being evaluated: ….. (Supplemental Substance Use forms are available if more than one person is to be evaluated.)
No use‚ Use; but no problem‚ Use; but it helps me‚ Moderate problem‚ Severe problem‚ Extremely severe problem
·         Alcohol
·         Tobacco
·         Marijuana
·         Other Street Drugs
·         Prescription Drugs
·         Over the Counter
·         Caffeine
During the past four weeks this family has (check one):
·         been ha‎ving good relationships with others and receiving support from family and friends
·         been receiving only moderate support from family and friends
·         had infrequent support from family and friends or only when absolutely necessary
GOAL ATTAINMENT
What are your goals for this family? Please write below up to 3 goals:
•        Goal 1: ______________________________________
How important is this goal? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
To what extent have you achieved this goal? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
•        Goal 2: ______________________________________
How important is this goal? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
To what extent have you achieved this goal? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
•        Goal 3: ______________________________________
How important is this goal? Not at all important 1 2 3 4 5 6 7 8 9 10 Extremely Important
To what extent have you achieved this goal? Not at all achieved 1 2 3 4 5 6 7 8 9 10 Completely achieved
·         Please check the box below to indicate your rating of this family’s quality of family life during the past four weeks. Lowest quality means things are as bad as they could be. Highest quality means things are the best they could be. LOWEST QUALITY 1 2 3 4 5 6 7 8 9 10 HIGHEST QUALITY
·         How confident are you that your rating of this family’s quality of family life is accurate? (Check one): Not at all confident‚ Quite confident‚ Very confident‚ Absolutely confident
·         Has a child from this family ever been placed outside the home? Yes‚ No‚ If yes; for how long?
·         Which child/children was it?
·         Do you believe that this family would be better off if a child was placed outside the home? Yes‚ No
·         If yes‚ which child/children are you referring to?
·         Is it possible that a child may be placed out of the home in the future? Yes‚ No
How important are each of the following factors in determining your client’s quality of family life?
Not at all important‚ Slightly important‚ Moderately important‚ Very important‚ Extremely important
•              Family activities
•              Feelings about the family
•              Physical health of family
•              Friends‚ people they spend time with outside of the family
•              Ability to take care of themselves and the family
•              Emotional health
•              Other‚ please specify:
 
1) Activities of daily living‚ 2) psychological well-being physical health‚ 3) social relations /Support‚ 4) Money‚ 5) alcohol and other drug abuse‚ and 6) goal attainment
 
This instrument can be found at: http://wqli.fmhi.usf.edu/wqli-instruments/
If you have any questions about this questionnaire‚ please call or write Marion Becker‚ Ph.D.‚ University of South Florida‚ Department of Community Mental Health‚ 13301 Bruce B. Downs Blvd.‚ MHC 1423‚ Tampa‚ Florida 33612-3899 Telephone: (813)974-7188 Fax: (813)974-6469 E-Mail: [email protected]