Pastoral Care: Sexual Health Assessment Checklist
To complete this form before printing it:
- Before entering your answers, go to a print-friendly version of this page. Newer browsers will let you drag-to-expand text boxes for more room. Complete the checklist, then print the page as you would normally.
- Or, download the Word 2010 version (46 pages, see 18-23) with form fields that will expand as you type.
- Or, download the PDF version (46 pages, see 18-23)—Nitro Reader will let you type text in the document (though text boxes won't expand).
| Reporting requirements | Yes | No | Don't Know | Plans for Improvement | |
|---|---|---|---|---|---|
| Do you know the state law about when clergy must violate confidentiality to: | Prevent a crime? | ||||
| Report a crime? | |||||
| Report child abuse? | |||||
| Report child pornography use? | |||||
| Protect someone from suicide? | |||||
| Training | Yes | No | Don't Know | Plans for Improvement | |
| Have you had training on counseling on sexuality issues in general? | |||||
| Have you had training on premarital counseling? | |||||
| Have you had training on working with couples with relationship issues? | |||||
| Have you had training in divorce mediation? | |||||
| Have you taken a course on pregnancy options counseling? | |||||
| Have you taken a course on working with sexual abuse survivors? | |||||
| Do you know the PLISSIT model? | |||||
| Yes | No |
Feel Comfortable Without |
Plans for Improvement |
||
|---|---|---|---|---|---|
| Have you had specialized training in these areas: | Adolescents? | ||||
| Bisexual adults? | |||||
| Couples counseling? | |||||
| Couples affected by infidelity? | |||||
| Couples during pre-marital counseling? | |||||
| Couples struggling with infertility or ART's? | |||||
| Disabled persons? | |||||
| Intersex individuals and families with an intersex child? | |||||
| Families with gender variant children? | |||||
| Families with LGB children/grandchildren and families with LGB parents/grandparents? | |||||
| Gay and lesbian adults? | |||||
| People involved in alternative sexual communities? (i.e., kink, bdsm, online role playing) | |||||
| People with cognitive disabilities? | |||||
| People with HIV/AIDS? | |||||
| People with mental health issues? | |||||
| Polyamorous individuals/families? | |||||
| Transgender adults? | |||||
| Young adults 18 - 24? | |||||
| LGBT youth? | |||||
| Survivors of sexual abuse and/or domestic violence/sexual assault? | |||||
| Persons convicted of sexual offenses? | |||||
| Yes | No | Plans for Improvement | ||
|---|---|---|---|---|
| Do you have up-to-date reading lists to give to congregants on these topics: | Adolescence? | |||
| Bisexuality? | ||||
| Couples Enrichment? | ||||
| Infertility or ART's? | ||||
| Sexuality and Disabilities? | ||||
| Intersex | ||||
| Gender variant children? | ||||
| LGBT issues? | ||||
| Alternative Sexual Communities? (i.e., kink, bdsm, online role playing) | ||||
| HIV/AIDS? | ||||
| Polyamory? | ||||
| Transgender | ||||
| LGBT youth? | ||||
| Sexual abuse and domestic violence/sexual assault? | ||||
| Yes | No | Don't Know | Plans for Improvement | ||
|---|---|---|---|---|---|
| Do you have outside experts for referrals for: | Adolescents? | ||||
| Bisexual adults? | |||||
| Couples Affected by Infidelity? | |||||
| Couples during pre-marital counseling? | |||||
| Couples struggling with infertility or ART's? | |||||
| Disabled persons? | |||||
| Intersex individuals, including families with an intersex child? | |||||
| Families with gender variant children? | |||||
| Families with LGB children? | |||||
| Gay and lesbian adults? | |||||
| People involved in alternative sexual communities? (i.e., kink, bdsm, online role playing) | |||||
| People with cognitive disabilities? | |||||
| People with HIV/AIDS? | |||||
| People with mental health issues? | |||||
| Polyamorous individuals/families? | |||||
| Transgender adults? | |||||
| Young adults 18 - 24? | |||||
| Couples? | |||||
| LGBT youth? | |||||
| Survivors of sexual abuse and/or domestic violence/sexual assault? | |||||
| Sexual offenders? | |||||
| Referral Lists/ Networks / Network | Yes | No |
Plans for Improvement |
|
|---|---|---|---|---|
| Does your referral list include: | Certified Marriage and family therapists? | |||
| Certified Sexuality counselors and therapists? | ||||
| Sex Abuse Treatment Specialists? | ||||
For more information contact safecongregations @ uua.org.
This work is made possible by the generosity of individual donors and congregations. Please consider making a donation today.
Last updated on Wednesday, May 23, 2012.
Updated and Popular
Popular New Searches
For Newcomers
Learn more about the Beliefs & Principles of Unitarian Universalism, or read our online magazine, UU World, for features on today's Unitarian Universalists. Visit an online UU church, or find a congregation near you.