Supports for Caregivers Survey

Over the last year you have received support from a program connected with the Edmonton and area Fetal Alcohol Network Society. Your feedback on your experiences will help us to evaluate and improve the services. Thank you for taking the time to complete this survey. Your responses are entirely voluntary and you may refuse to complete any part or all of this survey.

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* 1. Please enter the date the survey was completed.

Date

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* 2. Please select the agency/program you are receiving services through.

CASA: FasTracs

CASA: Indigenous Services

Catholic Social Services: Coaching Families Program

Elves: FASD Respite Program

Other (please specify)

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* 3. Age of your child/children/dependents (please select all that apply).

0 - 5 years old

6 - 12 years old

13 - 17 years old

18+ years old

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* 4. Please check the box that best fits how you feel about the following questions/statements.

	I strongly disagree.	I disagree.	I neither agree or disagree.	I agree.	I strongly agree.	N/A
I am satisfied with the services I received from the agency/program.	I am satisfied with the services I received from the agency/program. I strongly disagree.	I am satisfied with the services I received from the agency/program. I disagree.	I am satisfied with the services I received from the agency/program. I neither agree or disagree.	I am satisfied with the services I received from the agency/program. I agree.	I am satisfied with the services I received from the agency/program. I strongly agree.	I am satisfied with the services I received from the agency/program. N/A
Agency/program staff treat me with respect.	Agency/program staff treat me with respect. I strongly disagree.	Agency/program staff treat me with respect. I disagree.	Agency/program staff treat me with respect. I neither agree or disagree.	Agency/program staff treat me with respect. I agree.	Agency/program staff treat me with respect. I strongly agree.	Agency/program staff treat me with respect. N/A
I have an increased understanding of FASD and how it affects my child/children/dependents.	I have an increased understanding of FASD and how it affects my child/children/dependents. I strongly disagree.	I have an increased understanding of FASD and how it affects my child/children/dependents. I disagree.	I have an increased understanding of FASD and how it affects my child/children/dependents. I neither agree or disagree.	I have an increased understanding of FASD and how it affects my child/children/dependents. I agree.	I have an increased understanding of FASD and how it affects my child/children/dependents. I strongly agree.	I have an increased understanding of FASD and how it affects my child/children/dependents. N/A
I feel more confident in my skills to parent/care for my child/children/dependents.	I feel more confident in my skills to parent/care for my child/children/dependents. I strongly disagree.	I feel more confident in my skills to parent/care for my child/children/dependents. I disagree.	I feel more confident in my skills to parent/care for my child/children/dependents. I neither agree or disagree.	I feel more confident in my skills to parent/care for my child/children/dependents. I agree.	I feel more confident in my skills to parent/care for my child/children/dependents. I strongly agree.	I feel more confident in my skills to parent/care for my child/children/dependents. N/A
My level of stress has decreased.	My level of stress has decreased. I strongly disagree.	My level of stress has decreased. I disagree.	My level of stress has decreased. I neither agree or disagree.	My level of stress has decreased. I agree.	My level of stress has decreased. I strongly agree.	My level of stress has decreased. N/A
I have experienced an improvement in my wellbeing.	I have experienced an improvement in my wellbeing. I strongly disagree.	I have experienced an improvement in my wellbeing. I disagree.	I have experienced an improvement in my wellbeing. I neither agree or disagree.	I have experienced an improvement in my wellbeing. I agree.	I have experienced an improvement in my wellbeing. I strongly agree.	I have experienced an improvement in my wellbeing. N/A
I have been given information and resources regarding FASD and supports available to me and my child/children/dependents.	I have been given information and resources regarding FASD and supports available to me and my child/children/dependents. I strongly disagree.	I have been given information and resources regarding FASD and supports available to me and my child/children/dependents. I disagree.	I have been given information and resources regarding FASD and supports available to me and my child/children/dependents. I neither agree or disagree.	I have been given information and resources regarding FASD and supports available to me and my child/children/dependents. I agree.	I have been given information and resources regarding FASD and supports available to me and my child/children/dependents. I strongly agree.	I have been given information and resources regarding FASD and supports available to me and my child/children/dependents. N/A
I am involved in planning the services I receive.	I am involved in planning the services I receive. I strongly disagree.	I am involved in planning the services I receive. I disagree.	I am involved in planning the services I receive. I neither agree or disagree.	I am involved in planning the services I receive. I agree.	I am involved in planning the services I receive. I strongly agree.	I am involved in planning the services I receive. N/A
I am satisfied with the services I receive.	I am satisfied with the services I receive. I strongly disagree.	I am satisfied with the services I receive. I disagree.	I am satisfied with the services I receive. I neither agree or disagree.	I am satisfied with the services I receive. I agree.	I am satisfied with the services I receive. I strongly agree.	I am satisfied with the services I receive. N/A

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* 5. The agency/program helped me in the following areas: (Please check all that apply).

Physical Health (doctor, dentist, nutritionist, recreation...)

Attachment (emotional bond with child, playing together...)

Family Cohesion (safety, stability)

Social Functioning (healthy social gatherings)

Mental Health and Regulation (referral and access, strategies...)

Education (school attendance, education supports...)

Identity (strengths, interests, cultural connections...)

Community Engagement (things to do, social network...)

Adaptive Skills (routines, schedules, hygiene, taking the bus...)

Employment and Finances

Housing

Parenting (skill development)

Access to FASD assessment services

Access to other community resources

Other (please specify)

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* 6. I require further assistance in the following areas: (Please check all that apply).

Physical Health (doctor, dentist, nutritionist, recreation...)

Attachment (emotional bond with child, playing together...)

Family Cohesion (safety, stability)

Social Functioning (healthy social gatherings)

Mental Health and Regulation (referral and access, strategies...)

Education (school attendance, education supports...)

Identity (strengths, interests, cultural connections...)

Community Engagement (things to do, social network...)

Adaptive Skills (routines, schedules, hygiene, taking the bus...)

Employment and Finances

Housing

Parenting (skill development)

Access to FASD assessment services

Access to other community resources

Other (please specify)

Supports for Caregivers Survey