Participant Satisfaction and Family Impact Survey

Thank you for completing our survey! Your responses to this survey are confidential. If you need assistance completing the form, please ask a member of the staff.

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* 1. Which Parent Child Center are you connected to? (see dropdown menu)

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* 2. Date

Date

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* 3. How long have you/your family been involved with us?

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* 4. How did you hear about us? (check all that apply)

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* 5. Which of these have you used from this center within the past year? (check all that apply):

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* 6. At this center:

  Not At All Sometimes Frequently Always
Staff members are welcoming and respectful
The services/supports I received had a positive impact for me and my family 
I received the help that I needed/was right for me
I would recommend the services/supports to a family or friend

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* 7. Other comments/ideas/questions you would like to share with us?

For the questions below, please tell us how you felt BEFORE you received Parent Child Center services/supports and how you feel TODAY.

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* 8. I have relationships with people who provide me with support when I need it.                  

  Always Mostly Sometimes Rarely Never
Before
Today

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* 9. I feel strong and confident as a parent.

  Always Mostly Sometimes Rarely Never
Before
Today

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* 10. I feel able to handle stressful events.

  Always Mostly Sometimes Rarely Never
Before
Today

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* 11. When I am worried about my child, I have someone to talk with.

  Always Mostly Sometimes Rarely Never
Before
Today

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* 12. I take good care of my child(ren) even when I have personal problems

  Always Mostly Sometimes Rarely Never
Before
Today

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* 13. I manage the daily responsibilities of being a parent/caregiver

  Always Mostly Sometimes Rarely Never
Before
Today

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* 14. I understand my child(ren)’s development

  Always Mostly Sometimes Rarely Never
Before
Today

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* 15. I know where I can get helpful information about parenting and taking care of children

  Always Mostly Sometimes Rarely Never
Before
Today

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* 16. Please share any other comments.

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