Youth Matrix Interview Form

Youth Matrix Interview Form

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FY 2024/25

Dear Form Editor(s),

If you have not yet completed this form, please check the "Save my progress and resume later" box instead of clicking "Submit." You may choose to whom you would like to email your "form is saved" email notification if collaborating with others, or you may send it to yourself and forward the email notification you will receive with the password to your collaborators. Please only click "Submit" when the form is 100% complete.

Please use/open forms that are pre-filled with student name via the Salesforce-generated Youth Matrix Form Link to ensure the form is stored in the student's contact record. To find a pre-filled form link and view the training on how to complete a Youth Matrix Form, please review this presentation:

Youth Matrix Training Guide

Evaluation Period

Elementary or Teen (Middle & High School)

Program Location

Director Email

Person(s) Conducting Interview (First and Last Name)

If multiple people, please include names of all people who participated

Student Name

First and Last Name should automatically appear when form is opened with connected form link to their Salesforce Contact Record

Student Salesforce ID

Interview Youth Matrix Score Summary

1. Perceived Social Support

2. Role of Education

3. Child Safety

4. Perceived Parental Support

"0" = N/A or No Data

Interview With Student

What was the most significant change you experienced as a result of your participation in our after school program?

1. Perceived Social Support

Instructions: According to the child's response, select the best answer.

1. My friends care about my feelings:

YesNoDon't Know/No Response

2. I feel like my friends leave me out of activities:

YesNoDon't Know/No Response

3. I have a friend that I feel comfortable going to when I feel down:

YesNoDon't Know/No Response

Total Points

YOUTH MATRIX SCORE

Notes for perceived social support:

2. Role of Education

Instructions: According to the child's response, select the best answer.

1a. Do you think education is important?

YesNoMaybeDon't Know/No Response

1b. Why or why not?

For You: Did the child respond immediately or need additional prompting?

Responded ImmediatelyNeeded Additional PromptingI Don't Know/ No Response

2. What educational goal(s) do you want to achieve in the next 4 months (Note: If the child does not understand the question, ask: "What do you hope to learn in school in the near future?")

For You: Did the child respond immediately or need additional prompting?

Responded ImmediatelyNeeded Additional PromptingI Don't Know/ No Response

3. How can you achieve those goal(s)?

For You: Did the child respond immediately or need additional prompting?

Responded ImmediatelyNeeded Additional PromptingI Don't Know/ No Response

4. In the next 10 years, what goal(s) do you want to achieve that are career-related (Note: If the child does not understand the question, ask: "What do you want to be when you grow up?")

For You: Did the child respond immediately or need additional prompting?

Responded ImmediatelyNeeded Additional PromptingI Don't Know/ No Response

5. How can you achieve this goal / these goals (for Teens: How did you hear about this career)?

For You: Did the child respond immediately or need additional prompting?

Responded ImmediatelyNeeded Additional PromptingI Don't Know/ No Response

Total Points

Total Points Divided by Total Points Possible

YOUTH MATRIX SCORE

Notes for role of education:

3. Child Safety

Instructions: Select the answer provided by the student. In the event of suspected abuse or neglect, contact your supervisor immediately and implement abuse and neglect protocol.

1. Has an adult often or very often...Sworn at you, insulted you, put you down, threatened you, humiliated you, or acted in a way that made you afraid that you might be physically hurt?

YesNoNo Response/Unwilling to Answer

2. If you ever feel unsafe, do you feel comfortable talk to a teacher or other adult at school?

YesNoNo Response/Unwilling to Answer

If yes, then who?

3. Has an adult often or very often...Pushed, grabbed, slapped, thrown something at you, or ever hit you so hard that you had marks or were injured?

YesNoNo Response/Unwilling to Answer

4. Do you feel safe playing outside your house and in your neighborhood?

YesNoNo Response/Unwilling to Answer

5. Has an adult or person at least 5 years older than you ever...touched you in an uncomfortable way or has made you touch their body in a way that made you feel uncomfortable?

YesNoNo Response/Unwilling to Answer

6. Do you feel safe around your classmates?

YesNoNo Response/Unwilling to Answer

7. Do you often or very often feel that...no one loves your or thinks you are important or special? Or, that no one looks out for each other, feels close to each other, or supports each other?

YesNoNo Response/Unwilling to Answer

8. Has an adult ever made you feel unsafe?

YesNoNo Response/Unwilling to Answer

9. Do you often or very often feel that...you don't have enough to eat, had no option but to wear dirty clothes, had no one to protect you, or your caretaker(s) were too drunk or high to take care of you or take you to the doctor if you needed it?

YesNoNo Response/Unwilling to Answer"Caretaker" might be paraphrased into adult who lives in the home with the child, parent, guardian, etc.

10. Has anyone ever hurt you on purpose while at school or in your neighborhood?

YesNoNo Response/Unwilling to Answer

Total Points

YOUTH MATRIX SCORE

Notes for child safety (if any question is answered with the child experiencing an unsafe event, please write down their response and any relevant details. Try to include specific details such as name and association to alleged perpetrator, date, and time. Do not ask leading questions.):

4. Perceived Parental Support

Instructions: According to the child's response, select the best answer.

Name(s) of Caretaker(s) & Relationship to Child

"Caretaker" can be anyone you spend a significant amount of time with.

1. A caretaker (parent/legal guardian) enjoys hearing about how I feel:

YesNoDon't Know/No Response

2. Most of my friends have a better relationship with their caretaker/parent(s) than I do with my caretaker (parent/legal guardian):

YesNoDon't Know/No Response

3. My caretaker (parent/legal guardian) wants to know about my school day:

YesNoDon't Know/No Response

4. I feel uncomfortable when I tell my caretaker (parent/legal guardian) something personal:

YesNoDon't Know/No Response

5. My caretaker (parent/legal guardian) likes a lot of the same things I do:

YesNoDon't Know/No Response

6. I feel that I can go to my caretaker (parent/legal guardian) when I am feeling down:

YesNoDon't Know/No Response

7. My caretaker (parent/legal guardian) and I are open about how we feel about things:

YesNoDon't Know/No Response

8. When I have a problem, my caretaker (parent/legal guardian) is good at helping me figure out what to do:

YesNoDon't Know/No Response

9. When I am upset, I can go to my caretaker (parent/legal guardian) for help:

YesNoDon't Know/No Response

10. I wish my caretaker (parent/legal guardian) was much different:

YesNoDon't Know/No Response

Total Points

YOUTH MATRIX SCORE

Notes for perceived parental support:

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