Reason for Visit

PARTICIPANT INFORMATION SURVEY

Thank you for taking the time to complete this survey. We use this information to help us plan services to meet the needs of the families we serve, and to tell our funders about who uses FamilyResourceCenter services. Your response to this survey is voluntary and your responses will not be connected to you or your family.

1. Date: ______2. Sex: Male  Female

3. My Date of Birth is: / / / /

4. I am a person with a disability: Yes  No5. Number of children with a disability: ______

6. My race/ethnicity is:(check all that apply)

 White Asian Multi-racial

Hispanic/LatinoNative Hawaiian/other Pacific Islander  Other ______

Black/African AmericanAmerican Indian/Alaskan Native______

7. Number of adults living in my household: ______Number of children living in my household: ______

-Please tell us the age and sex of each of your children: (if more than 6, write on back)

Currently pregnant
 / Child 1
Age: ____
M F / Child 2
Age: ____
M F / Child 3
Age: ____
M F / Child 4
Age: ____
M F / Child 5
Age: ____
M F / Child 6
Age: ____
M F

8. Household income: $______ (write in amount and check the box that applies)

 WeeklyBiweeklyMonthlyAnnual

9. I am: (check all that apply)

A stay-at-home parent Employed full time Retired

A student Employed part time Serving in the military

 A temporary/seasonal worker Receiving SSI for disabilityUnemployed

10. My relationship to the children in my household is: (check all that apply)

Birth parentStep parentGrandparent/Great-grandparent

Foster parentAdoptive parentOther relativeNon-relative

11. My family is currently dealing with: (check all that apply)

Divorce or separationAlcohol or drug abuseJob loss/unemployment

Child custody disputeMental health issuesStruggling to make ends meet

 Death in the family Relocation/moving Homelessness

Raising a child with special needsTeen pregnancy/parenting

Child Protective Services involvementIncarceration/probation/parole

 Other: ______ Prefer not to answer

Please note: We use this information to help us understand the needs of the families we serve.
If you would like assistance with these or any other issues, please talk to a staff member.

12. My / First Initial: / Middle Initial: / Last Initial: