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How We Can Assist You Survey

* The following demographic information is optional.

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

Ethnic Group:

* This information will be used to better serve you and your family.

2. What is the age range of your son(s)? Please check all that apply

0-5

6-10

11-14

15-21

* 3. Below are 5 concerns that have been expressed by single mothers raising boys across the country, and we would like to know what concerns you most.

On a scale of 1 to 5 please rate the following concerns.
1 being the least concern and 5 being the greatest concern.

	Extremely Important	Very Important	Mildly Important	Somewhat Important	Not Important	N/A
Academic Achievement	Academic Achievement Extremely Important	Academic Achievement Very Important	Academic Achievement Mildly Important	Academic Achievement Somewhat Important	Academic Achievement Not Important	Academic Achievement N/A
Father Involvement	Father Involvement Extremely Important	Father Involvement Very Important	Father Involvement Mildly Important	Father Involvement Somewhat Important	Father Involvement Not Important	Father Involvement N/A
Finding Male Mentors	Finding Male Mentors Extremely Important	Finding Male Mentors Very Important	Finding Male Mentors Mildly Important	Finding Male Mentors Somewhat Important	Finding Male Mentors Not Important	Finding Male Mentors N/A
Peer Pressure	Peer Pressure Extremely Important	Peer Pressure Very Important	Peer Pressure Mildly Important	Peer Pressure Somewhat Important	Peer Pressure Not Important	Peer Pressure N/A
School Environment	School Environment Extremely Important	School Environment Very Important	School Environment Mildly Important	School Environment Somewhat Important	School Environment Not Important	School Environment N/A
Finances	Finances Extremely Important	Finances Very Important	Finances Mildly Important	Finances Somewhat Important	Finances Not Important	Finances N/A
Day Care/Child Care	Day Care/Child Care Extremely Important	Day Care/Child Care Very Important	Day Care/Child Care Mildly Important	Day Care/Child Care Somewhat Important	Day Care/Child Care Not Important	Day Care/Child Care N/A
Other (please specify)	Other (please specify) Extremely Important	Other (please specify) Very Important	Other (please specify) Mildly Important	Other (please specify) Somewhat Important	Other (please specify) Not Important	Other (please specify) N/A

* 4. Please specify if you stated other in the previous question:

* 5. Do you feel that your son has a positive male role model? (Ex. Other family members, teachers, mentors etc.)

* 6. Are there free or affordable after school activities and resources available for your son in your community? (Recreation Center, Sports Team, clubs, etc.)

* 7. Do you have free/personal time to do something for yourself (Ex. relaxing, exercise, hobby). If not, how does this effect your daily life?

* 8. Do you have any concerns about your housing or neighborhood? (Crime, Gang Activity, etc.)

* 9. During these troubling economic times are you and your son's basic needs being met? Such as (food, clothes, etc.)

Yes

No

Somewhat

* 10. How would you rate your son and his father's relationship?

					N/A
Exceptional	Exceptional	Exceptional	Exceptional	Exceptional	Exceptional N/A
Great	Great	Great	Great	Great	Great N/A
Okay	Okay	Okay	Okay	Okay	Okay N/A
Non-existant	Non-existant	Non-existant	Non-existant	Non-existant	Non-existant N/A