Mothering in the field Survey

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1. Your specific information will remain confidential however the data collected from all the participants' responses will be used for research and educational purposes within the member care mental health community. Please list your organization name (abbreviations acceptable), predominant country of service (list the country you've spent the most time in serving), and email. We will use this demographic data to sort responses based on country and/or international region, and its impact on mothering. Your email is to verify that only one submission is given per Mom. In addition, if you'd like to receive results of the survey, we will send you results to this email listed.

Your specific information will remain confidential however the data collected from all the participants' responses will be used for research and educational purposes within the member care mental health community. Please list your organization name (abbreviations acceptable), predominant country of service (list the country you've spent the most time in serving), and email. We will use this demographic data to sort responses based on country and/or international region, and its impact on mothering. Your email is to verify that only one submission is given per Mom. In addition, if you'd like to receive results of the survey, we will send you results to this email listed. Company:
Country:
Email Address:

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2. Approximately when did you enter the field?

	MM		DD		YYYY
Service began	Approximately when did you enter the field? Service began Month	/	Day	/	Year

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3. Approximately when did you become a Mom?

	MM		DD		YYYY
Motherhood began	Approximately when did you become a Mom? Motherhood began Month	/	Day	/	Year

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4. How many children do you have?

How many children do you have? One

Two

Three

Four

Five

Six or more

5. Please rate the following traits addressing how well your SPOUSE understands and supports:

	Poor	Fair	Neutral	Good	Excellent
Your emotional needs	*Please rate the following traits addressing how well your SPOUSE understands and supports: Your emotional needs Poor	Your emotional needs Fair	Your emotional needs Neutral	Your emotional needs Good	Your emotional needs Excellent
Your role as a Mom	Your role as a Mom Poor	Your role as a Mom Fair	Your role as a Mom Neutral	Your role as a Mom Good	Your role as a Mom Excellent
Your children's emotional needs	Your children's emotional needs Poor	Your children's emotional needs Fair	Your children's emotional needs Neutral	Your children's emotional needs Good	Your children's emotional needs Excellent
Your marriage needs	Your marriage needs Poor	Your marriage needs Fair	Your marriage needs Neutral	Your marriage needs Good	Your marriage needs Excellent

6. Please rate the following traits addressing how well your TEAM understands and supports:

	Poor	Fair	Neutral	Good	Excellent
Your emotional needs	*Please rate the following traits addressing how well your TEAM understands and supports: Your emotional needs Poor	Your emotional needs Fair	Your emotional needs Neutral	Your emotional needs Good	Your emotional needs Excellent
Your role as a Mom	Your role as a Mom Poor	Your role as a Mom Fair	Your role as a Mom Neutral	Your role as a Mom Good	Your role as a Mom Excellent
Your children's emotional needs	Your children's emotional needs Poor	Your children's emotional needs Fair	Your children's emotional needs Neutral	Your children's emotional needs Good	Your children's emotional needs Excellent
Your marriage needs	Your marriage needs Poor	Your marriage needs Fair	Your marriage needs Neutral	Your marriage needs Good	Your marriage needs Excellent

7. Please rate the following traits addressing how well your ORGANIZATION understands and supports:

	Poor	Fair	Neutral	Good	Excellent
Your emotional needs	*Please rate the following traits addressing how well your ORGANIZATION understands and supports: Your emotional needs Poor	Your emotional needs Fair	Your emotional needs Neutral	Your emotional needs Good	Your emotional needs Excellent
Your role as a Mom	Your role as a Mom Poor	Your role as a Mom Fair	Your role as a Mom Neutral	Your role as a Mom Good	Your role as a Mom Excellent
Your children's emotional needs	Your children's emotional needs Poor	Your children's emotional needs Fair	Your children's emotional needs Neutral	Your children's emotional needs Good	Your children's emotional needs Excellent
Your marriage needs	Your marriage needs Poor	Your marriage needs Fair	Your marriage needs Neutral	Your marriage needs Good	Your marriage needs Excellent

8. Please check if you experienced any of the below since entering the field. Check all that apply.

Please check if you experienced any of the below since entering the field. Check all that apply. Serious medical illness

Serious medical illness in children or spouse

Transportation accidents

Death in the family or of a close friend

Direct exposure to unrest or war in region of service

Robbery in home without confrontation

Robbery in home with confrontation

Serious harm to you, a family or team member

Witness to serious harm to a family or team member

Imprisonment and/or police questioning for service in country

Evacuation

Spiritual warfare

Witness to demonic activity

9. Please check whether you have received or would be willing to receive emotional support from the following:

	Not at all likely	Probably not likely	Neutral	Probably likely	Most likely
Your team	*Please check whether you have received or would be willing to receive emotional support from the following: Your team Not at all likely	Your team Probably not likely	Your team Neutral	Your team Probably likely	Your team Most likely
Your organization member care	Your organization member care Not at all likely	Your organization member care Probably not likely	Your organization member care Neutral	Your organization member care Probably likely	Your organization member care Most likely
Outside your agency counseling support	Outside your agency counseling support Not at all likely	Outside your agency counseling support Probably not likely	Outside your agency counseling support Neutral	Outside your agency counseling support Probably likely	Outside your agency counseling support Most likely
Home church	Home church Not at all likely	Home church Probably not likely	Home church Neutral	Home church Probably likely	Home church Most likely
Family	Family Not at all likely	Family Probably not likely	Family Neutral	Family Probably likely	Family Most likely
Personal friends	Personal friends Not at all likely	Personal friends Probably not likely	Personal friends Neutral	Personal friends Probably likely	Personal friends Most likely
Social networking	Social networking Not at all likely	Social networking Probably not likely	Social networking Neutral	Social networking Probably likely	Social networking Most likely

10. Please check below if you have concerns for the mental health of any of the following. Check all that apply.

Please check below if you have concerns for the mental health of any of the following. Check all that apply. Yourself

Your children

Your spouse

Your team members

Mothering in the fieldExit this survey

*2. Approximately when did you enter the field?

*3. Approximately when did you become a Mom?

*4. How many children do you have?