🔒 100% Confidential · Your answers are private

Family Wellness Assessment

This 4-section questionnaire helps us understand your situation and connect you with the right support.

Profile & Identity

Family Filter

Substance & Behaviour

Safety & SOS

✓

Complete

Consent & Basic Profile

Full Name

Email Address

Gender

♂ Male

♀ Female

🔄 Other

Family Structure

🏠 Nuclear Family

👨‍👩‍👧‍👦 Joint Family

👩 Single Parent

🔄 Other

Child Status

👤 Only Child

👥 Elder Sibling

👥 Younger Sibling

Primary Concern (select all that apply)

💬 Communication Gap

🧒 Only-Child Dynamics

💊 Substance Use

🚨 Domestic Safety

😟 Anxiety / Depression

🔄 Other

Consent to Treatment

Step 1 of 4

The Only Child & Nuclear Family Filter

Parental Expectations Pressure

On a scale of 1–10, how much pressure do you feel to succeed for your family?

Low High

Horizontal Support

Do you have someone outside your parents (cousin, friend) you can talk to about "everything"?

✅ Yes

❌ No

Intergenerational Conflict

"My parents/children and I have completely different values regarding..."

💼 Work & Career

💍 Marriage

🌐 Lifestyle

📱 Technology

Household Composition

Step 2 of 4

Substance & Behavioural Screening

Usage Interference

Has substance use (alcohol, drugs, prescription meds) interfered with work or family roles in the last 30 days?

✅ Yes — my own use

👥 A family member's

❌ No

🤷 Unsure

Family Impact

Has a family member's usage ever made you feel unsafe or financially unstable?

✅ Yes

❌ No

When stressed by family, what is your primary coping response?

🚪 Isolation

🍺 Substance Use

🏃 Exercise

😤 Confrontation

Step 3 of 4

Safety & SOS — Immediate Red Flags

🛡️ These questions help us prioritize your safety. Your answers are confidential and never judged.

Physical Safety

Have you been pushed, hit, or physically restrained by anyone in your home in the last 6 months?

✅ Yes

❌ No

Immediate Threat

Is there someone in your home right now that you are afraid of?

✅ Yes

❌ No

Self-Harm Thoughts

In the past two weeks, have you had thoughts that you would be better off dead, or of hurting yourself?

✅ Yes

❌ No

🆘

You are not alone — help is available right now

Based on your answers, we strongly encourage you to reach out to a crisis professional immediately. These helplines are free, confidential, and available 24/7.

Kiran 1800-599-0019

Vandrevala 9999 666 555

NCW 7827170170

Police 112

Step 4 of 4

✓

Assessment Complete!

Thank you for trusting KinVeda. Our team has received your assessment and will review it within 24 hours. You'll receive a personalized match and session invite by email.

✅ Profile Submitted

⏳ Matching in Progress

📧 Confirmation Sent

📋 Your Recommended Resources

These have been auto-pinned to your dashboard based on your responses:

📄 Only Child Survival Guide — Managing parental pressure & building lateral support

📄 Personal Safety Plan — Your customized SOS document

📄 Boundary Setting Workbook — For nuclear family stress

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