CULTURE SCREEN/INTERVIEW
CULTURE SCREEN/INTERVIEW
Child_____________________ _ Age____________
Facility______________________ Date_________________
Instructions: Facility staff completes this form based on information provided by the child.
HOW DO YOU IDENTIIFY YOURSELF IN TERMS OF:
Race
Ethnicity
Religion
Sexual Orientation
How does your culture influence your life?
What language is spoken in your home?
Do you have any dietary restrictions?
How important is it to you to have staff who are from the same culture?
Is it easier for you to relate to male or female staff?
Is it easier for you to relate to male or female peers?
Do you tend to feel unsafe with others of a particular culture or gender?
What would help you feel comfortable and accepted as you begin this program?
Signature of staff member who completed the screen Date
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