Patient Cultural Identity Assessment
Today I’m going to be asking you questions about different aspects of your identity Not all questions will apply to you, so just let me know about the experiences that feel relevant. The goal of these questions is to get to know as much about your life as I can. If there is anything I don’t ask about, feel free to let me know.
LIVING SITUATION AND RELATIONSHIPS
How old are you?What age related issues or influences affect you? / Age:
What is your living situation?
With whom do you live?
Are you satisfied with this arrangement?
How are your relationships with these people?
How long have you lived there? / Living Arrangement: (e.g., apartment, house, dorm, assisted living)
Tell me about your relationships with your family members.
Who raised you? Siblings?
Have you ever been married, partnered, or in a (long term) committed relationship? Currently?
(Note: Responses listed are to be used for the interviewer ONLY. Do not list possible responses aloud)
Have you ever had any children?
Do you have a personal connection to adoption?
Have you ever been a caregiver? (e.g., disabled parent or special needs child.)
Have you experienced any challenges in having the family or relationship you want? (e.g., financial, legal, medical, social, familial)
What major changes or conflicts has your family gone through? (e.g., deaths, divorce, financial hardships, etc.) / Family: (i.e., relationships, names, and ages)
Relationship Status:
1 – Single
2 – Dating
3 – Girlfriend/ Boyfriend
4 – Married or Partnered
5 – Separated
6 – Divorced or annulled
7 – Widowed
8 – Never married
9 – Other
GENDER, SEXUAL, ETHNIC IDENTITY
How would you describe your gender?How does your experience of your gender affect you? / Gender:
1 – Female
2 – Male
3 – Transgender
4 – Other
How would you describe your sexual orientation?
(Note: Take care to use the language of the interviewee. Responses listed are to be used for the interviewer ONLY. Do not list possible responses aloud.)
How has that shifted over time?
What are others’ reactions to your sexuality? / Sexual Orientation:
1 – Straight or heterosexual
2 – Gay or homosexual
3 – Bisexual
4 – Queer *
5 – Questioning
6 – Other
* The term “queer” sometimes is seen as a derogatory term. Take care to use the language of the interviewee.
Do you identify with a particular race or ethnic group?
What role does (stated identity) play in your life?
What is your family or community experience of race or ethnicity?
Have you ever had any difficulties related to (stated identity)?
Do you have any ties to indigenous culture? / Race, Ethnicity, Indigenous Heritage:
What is your primary language?
If not English: Do you feel comfortable conducting this interview in English? Did you have difficulties finding a clinician who spoke your language?
Do you speak any other languages?
In what contexts (e.g., at home, in your neighborhood, at school, at work) do you use these languages? / Language:
NATIONAL AND RELIGIOUS IDENTITY
Where were you born?Have you ever lived in another country?
What experiences have you had as a result of X (e.g., living in multiple countries)?
What challenges, if any, have you faced as the resuly of your experience. / National Origin and Nationality:
What role, if any, does religion or spirituality play in your life?
Do you follow a particular faith?
What is your family history of religion or spirituality? / Religion and Spirituality:
SOCIOECONOMIC IDENTITY- EDUCATION
Tell me about your education.Have you experienced any educational challenges?
Are you currently a student?
Half-time? Full-time?
If pursued a degree: What is the highest degree you have earned?
Were your educational plans cut short in any way due to family, health, financial or other reasons? / Education:
SOCIOECONOMIC IDENTITY - FINANCIAL
Are you employed right now?Since when have you been employed there? Half-time? Full-time?
If unemployed or disabled: What was the work you were doing most recently?
What is it like for you to be there/doing that work?
Have you had any other jobs in the past year?
Have you ever been unable to work? Why? / Employment:
SOCIOECONOMIC IDENTITY – FINANCIAL (cont).
How are you supporting yourself financially?Has there ever been a time when you had trouble supporting yourself or your family financially?
To what degree are financial issues on your mind at present?
Of which socio-economic class do you consider yourself to be a part?
How has that changed over your life?
EXPERIENCE WITH DISABILITIES
Do you currently have, or have you ever had, a physical or learning disability?What have you experienced as a result?
Has someone close to you?
Have you ever received any accomodations for your X?
Was this a life long disability or something that arose later in your life?
FOLLOW-UP QUESTIONS
To what degree have you been affected by discrimination or stigma?If unclear:
Sometimes people experience discrimination based on gender, ethnicity, or some other factor that can have an effect on them. Have you experienced anything like that?
What [other] significant changes have you experienced in your personality or how you see yourself with regard to any of the areas of your life we discussed?
Is there anything else important for me to know about who you are?
Therapist Cultural Self-Assessment Worksheet
*based on the ADRESSING Framework created by Hays (2008)*
Age
-What age-related issues or influences affect you?
-What are the norms and values of your age group?
-What are some privileges and disadvantages of belonging to your age group?
-How are you regarded by others as a member of your age group?
-Have there been shifts in the norms or values of your age-group during your life?
-What significant social movements and historical events have occurred during your
lifetime and how have they shaped your worldview?
Developmental and Acquired Disabilities
-What is your experience of physical or psychological disability? Yours, other people?
-Are they visible or invisible and how does this affect your experience?
Consider both chronic and transient disabilities:
Physical ailments Notable injuries and surgeries
Learning disorders Mental illness
-How do you manage your disabilities?
Religion and Spirituality
-What was your religious or spiritual upbringing? What are your beliefs and practices?
-Where do your religious or spiritual beliefs get practiced or expressed, if at all?
-Is your approach to religion or spirituality similar to others in your immediate, local,
regional or national communities?
-How have your religious or spiritual beliefs shifted over time?
-How do your religious or spiritual beliefs affect your worldview? How has religion
influenced the views you hold about your local, regional or national communities?
Ethnic Identity (Race and Culture)
-How would you describe your ethnic identity? How has it changed over time?
-How would you describe your racial identity? How has it changed over time?
-What differences exist between your race and ethnicity?
-To what extent have your explored your racial or ethnic identities?
-What cultural practices and rituals are associated with your ethnicity? How dominant
or marginal is this experience in your local, regional or national communities?
-What are the privileges and disadvantages associated with these identities?
-Do you feel your ethnic identity is expressed differently in different contexts?
Socio-economic Status
-What financial and social capital do you have?
-What privileges and disadvantages do these forms of capital offer to you?
-What economic class do you consider yourself to be part of currently, and how has
this changed over your life?What socio-economic class do you identify with most?
-What is your experience with and exposure to economic diversity?
-Did you grow up in an urban, suburban or rural setting? Currently?
-Are you mostly surrounded with others of the same class or different classes?
-How does gender, race, age, and education play a role in your socio-economic status?
Sexual Orientation
-How would you describe your sexual orientation? How has this shifted over time?
-Have you ever questioned or explored your sexuality?
-What support systems do you have with regard to your sexuality on an individual
level? Familial level? Community level? Systemic level?
-What are some of the “messages” have your received about your sexuality?
-What are your experiences “coming out” as a straight/gay/bisexual/queer person?
-What was your “coming out” experience like?
-What are others’ reactions to your sexuality? How has this affected you?
Indigenous Heritage
-Do you have tribal or indigenous ties? Consider tribal histories in your country of
origin as well.
-What are your former and current ties to tribal or indigenous heritage?
-What are your beliefs, norms, and cultural practices around your heritage?
-What stereotypes are you familiar with regarding your indigenous heritage?
-What are your experiences and feelings towards this?
-Are you a part of a community that shares your heritage?
National Origin
-In what country/countries do you currently reside? Formerly?
-Where do you hold citizenship? What are the privileges and disadvantages associated
with this status?
-How strong/weak are your ties to your country of origin? Do you feel a sense of
belonging or exile?
-What are the norms, beliefs, and cultural practices of your country of national origin?
-What languages do you speak? What are the associated privileges and disadvantages?
-How does your understanding of national origin shift in different contexts (e.g.,
traveling to a different state or country)?
-What stereotypes exist regarding your national origin? What is your experience and
feelings towards this?
Gender
-How do you describe your gender? What are associated privileges and disadvantages?
-What are the norms surrounding your gender? How does this reflect your experience?
-What experiences have been central to your gender identity? Have there been people
who you consider to be formative in understanding your gender?
-How have your feelings regarding gender changed over your lifetime?
-What gender related information regarding roles, expectations, and relationships is
significant given your cultural heritage and identity as a whole?
WHAT OTHER IDENTITES ARE IMPORTANT TO YOU THAT HAVE NOT BEEN ADDRESSED?
Intersectionality and Diagnosis Worksheet
PatientIdentities / Therapist Identities / Biases and
Assumptions / Systemic Influences / Diagnostic and Treatment Considerations
Age and
Generational
Influences
Developmental
and Acquired
Disability
Religion and Spirituality
Ethnic and Racial Identity
Socioeconomic Status and Education
Sexual Orientation
Indigenous Heritage
National Origin and Language
Gender
Other
Dadlani, Overtree, & Perry-Jenkins (2012)