1. Demographics

1. What is your marital status?

2. Where did you live prior to entering Casa de Vida?

3. What is your Age?

4. How many months until your due date?

5. Do you have other children?

6. How many children do you have?

7. My other children are:

8. I am

9. What is your current school status?

10. What is the highest grade you completed:

11. Are you or have you ever been in job training?

12. If you didn't finish your training tell us why?

13. Are you currently working?

14. If you are not working why?

15. How many hours are you currently working?

16. What is your main source of financial support?

  Own Job Spouse or partner Parents Public Assistance Other relatives
Check one response

17. Do you receive money or assistance from any of the following sources?

  Yes No
Social Security
Spouse or partner
Own Job
Child Support
Food stamps
General assistance or aother aid
Unemployment or Workers Compensation

18. Have you ever been given a mental health diagnosis?

19. What is your mental health diagnosis?

20. Have you ever lost a job because of your mental health problems?

21. What was your age when you were first diagnosed?