1.Please enter either 1.) your name or 2.) the date your class started

We want to respect everyone's right to privacy. If you do not wish to share your name in connection to this survey, please enter the start date of your class if you are comfortable doing so. This information is used to help us track community need and collect data relevant to grant writing. You are not obligated to complete this survey or provide information you do not wish to provide.

-The Parenting Place

2.Did you feel that you did not have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

Yes

No

3.Did you lose a parent through divorce, abandonment, death, or other reason?

Yes

No

4.Did you live with anyone who was depressed, mentally ill, or attempted suicide?

Yes

No

5.Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

Yes

No

6.Did the adults in your home ever hit, punch, beat, or threaten to harm each other?

Yes

No

7.Did you live with anyone who went to jail or prison?

Yes

No

8.Did a parent or adult in your home ever swear at you, insult you, or put you down?

Yes

No

9.Did a parent or adult in your home ever hit, beat, kick, or otherwise physically harm you?

Yes

No

10.Did you feel that no one in your family loved you or thought you were special?

Yes

No

11.Did you experience unwanted sexual contact (such as fondling and/or oral/anal/vaginal intercourse or penetration)

Yes

No