Collateral Questionnaire for a Loved One or Family Member Collateral Questionnaire For A Family Member Collateral QuestionnaireYour loved one is presently undergoing a psychological evaluation with Dr. Paul Simpson. As part of this assessment, it is particularly helpful for Dr. Simpson to interview you for additional perspective. Please be as honest as possible in your answers. Your effort on this questionnaire helps Dr. Simpson to create a more accurate and helpful assessment. Let’s start with some basics:Your Name First Last Today's Date MM slash DD slash YYYY Cell PhoneEmail Who are you reporting about in this questionnaire? What is your relationship to this person? How long have you known him/her? What has this person told you about their charges/legal situation?What was going on in this person’s life in the period leading up to their alleged offence(s)?Social Influences:Who are important people in this person’s life?What kind of support are they offering him/her now?Have any of these supportive people ever been in trouble with the law?Do they know about his/her charges/offences?Is this person considerate about the feelings of others?Intimate Relationship(Only answer this section if you are married or partnered with this person.)When did you first get together? MM slash DD slash YYYY Are you married? Yes No How do you feel emotionally with this partner?What do you have in common?What are some of the problems in the relationship?What does s/he do to deal with conflicts in your relationship? Who usually apologizes first?Has there been any emotional, physical, or sexual abuse?Have the police ever been called to your home?Has anyone ever complained about his behavior towards women?Does he have any convictions for offences that involved women?GeneralHow would you describe this person?How does s/he do to relax when not working?What are his/her hobbies?Is this person involved in any community groups, sports teams or clubs?Does s/he attend church or other religious services?Substance UseDoes this person ever drink or use other drugs when faced with problems?What is s/he like when drunk/high?Impulsive TendenciesDo you consider this person to be impulsive? Yes No Yes No If “yes”, what types of things do they do impulsively?Do they ever buy things that they really cannot afford or really do not need?Has s/he ever gotten really mad if someone cut them off in traffic? What did they do?Have s/he ever taken something without permission or paying for it?Has this person had difficulty managing their money?Has this person ever gotten into a bar-fight? What happened?Has s/he ever quit a job without having another one to go to?Have they ever been fired for breaking the rules at work or for engaging in unsafe practices?Do they like exciting pastimes such as street racing, skydiving, or “extreme sports”?Does this person like taking risks? What are examples of risks they have taken?Do they like to take chances when driving? Have they been arrested for speeding or DUI?How often do this person gamble? Has their gambling ever caused problems?Has s/he ever had a disagreement with an unreasonable co-worker that led to a fight at work?How often does this person drink alcohol or use other drugs?Have s/he ever had a problem with alcohol or other drugs?Problem SolvingWhat sorts of things cause problems in this person’s life?What does s/her manage those problems?How does this person deal with conflicts at work?With friends?Neighbors?Does this person ever feel like people are “just out to get them” or looking to harm them?Sexual HistoryHas this person ever told you that as a child they engaged in sexual exploration with siblings?Were they ever sexually abused as a child?How do you think this person’s sex drive compares to other adults? In your opinion is it higher than the norm, lower, or about average?Do they seem preoccupied with sex?Have they ever have a sexual affair while married or in a committed relationship?PornographyDo you know how often this person views erotic material, such as magazines, videos, internet?How do you feel about it their viewing habits?Does this person visit chat rooms? Do you know which ones?Do you know if they have ever done risky things online (been sexual with strangers, watched teen or child pornography, sent nude images of themselves?VariousDo you know if this person has ever gone to strip clubs?Do you know if this person has ever gone to massage parlors for sex?Do they have a “dirty mouth” because of the things they say? Has this caused problems?If you are married or partnered with this person, have the two of you ever engaged in a threesome or group sex activity? Couple swapping?Does this person have any special sexual interests that you think others generally do not or might not enjoy? What are they?If married or partnered with this person, has this ever-caused problems in your relationship?Sexual InterestsHas this person ever told you they think about children in a sexual way?Have this person ever exposed their genitals in public?Have they ever looked in windows or washrooms to view people undressing or using the facilities?Has this person ever rubbed up against someone for a sexual purpose without their knowledge or consent?Has this person ever had sex in a public place?Has this person ever engaged in Sadomasochistic sexual activities? (Dominating/hurting someone or being dominated/hurt?)Do they have any special sexual interests?(Some people are sexually aroused by items, such as high-heels, stockings or rubber and some are aroused by engaging in certain activities such as urinating on another person or wearing clothes of the opposite sex.)
