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* 1. Contact Information 

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* 2. Date of Birth

Date

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* 3. Gender

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* 4. Do you have a partner/spouse?

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* 5. Is your partner/spouse attending this program?

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* 6. Race (Please mark all that you identify with)

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* 7. Which of these best describes the highest level of education you have completed?

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* 8. Hispanic, Latino/Latina or Spanish national origin

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* 9. Primary language spoken at home? (Please choose one)

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* 10. Service in Military?

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* 11. Children in program (Name, Age, gender, and ethnicity of each child- If more than 3, please add them to "additional information" question at end of survey)

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* 12. Most parents and caregivers try to stay calm and loving when they guide and discipline their adolescent children. However, most parents fall short of these goals from time to time. Please take your time and answer the following questions candidly. Your answers will be kept completely confidential and will not be linked to your personal information. 

The following questions are about you. We are interested to know which aspects of parenting are most challenging for you. Your answers to these questions will help us better understand how and for whom the Strengthening Families Program works. 

How much do you agree or disagree with the following statements?

  Strongly Agree Agree Neutral or Mixed Disagree Strongly Disagree
I have clear and specific rules about my child's association with peers who use alcohol.
I have explained my rules about alcohol use to my child.
I have explained the consequences of breaking my rules about alcohol use to my child.
I can control my anger and frustration with my child.
I work hard with my child on ways to express and control their anger and frustration.
I find ways to keep my child involved with fun activities in our family.
I find ways to keep my child involved in family work activities (chores, for example).
I find ways to keep my child involved with family decisions about fun and work activities in a way that is appropriate for their age.
I have discussed my child's dreams and goals with him/her on many occasions.
I often tell my child how I feel when he or she misbehaves. 
When my child tells me something important, I let them know that I am trying to understand what they are feeling. 
I let my child know that I care about them while setting limits and consequences.
I have discussed our family values with my child on many occasions. 
Getting my youth to hep with chores is a problem.
Getting my youth to do homework is a problem. 

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* 13. Please show how you rate the tension among your family members.
Examples of "low tension" are:
Family members are peaceful and friendly
Talking with family is open and positive
Overall family mood is warm and loving
Examples of "High tension are:
Family members are "on edge" and impatient with each other
Talking with family is stressful
Overall, family mood is negative, angry and not agreeable

1 (Low) 10 (High)
Clear
i We adjusted the number you entered based on the slider’s scale.

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* 14. What additional information would you like to provide to the program facilitators and/or funders?

0 of 14 answered
 

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