Meltzer Caregiver PFS

Thank you for taking the time to fill out this survey! The information will be used to evaluate the program. For each of the questions, please answer in your own opinion or experience instead of trying to answer for other members of your family. Please answer honestly. There are no right or wrong answers.

If you have any questions about one of the statements or the answer scale, ask one of the program staff. Please do not skip a question.

My Therapist/Case Manager is:*

Caregiver

First NameLast Name

Caregiver Date of Birth

Today's Date

Date

PART 1. Please check the box that best describes how often the statements are true for you or your family.*

	Never	Very Rarely	Rarely	About Half the Time	Frequently	Very Frequently	Always	NA
1. In my family, we talk about problems
2. We we argue, my family listens to "both sides of the story."
3. In my family, we take time to listen to each other
4. My family pulls together when things are stressful
5. My family is able to solve our problems

Part II: Please check the box that best describes how much you agree or disagree with the statement.*

	Strongly Disagree	Mostly Disagree	Slightly Disagree	Neutral	Slightly Agree	Mostly Agree	Strongly Agree	N/A
6. I have others who will listen when I need to talk about my problems
7. When I am lonely, there are several people I can talk to.
8.I would have no idea where to turn if my family needed food or housing.
9. I wouldn't know where to go for help if I had trouble making ends meet.
10. If there is a crisis, I have others I can talk to.
11. If I needed help finding a job, I wouldn't know where to go for help.

Part III. This part of the survey asks about parenting and your relationship with your child. For this section, please focus on the child that you hope will benefit most from your participation in our services. Please write your child's age or date of birth and then answer questions with this child in mind. If you are expecting your first baby and there are no more children in your home, STOP here.

Child's Age

Child's Date of Birth

	Strongly Disagree	Mostly Disagree	Slightly Disagree	Neutral	Slightly Agree	Mostly Agree	Strongly Agree	N/A
12. There are many times when I don't know what to do as a parent.
13. I know how to help my child learn.
14. My child misbehaves just to upset me.

PART IV. Please tell us how often each of the following happens in your family.*

	Never	Very Rarely	Rarely	About Half the Time	Frequently	Very Frequently	Always	NA
15. I praise my child when he/she behaves well
16. When I discipline my child, I lose control
17. I am happy being with my child
18. My child and I are very close to each other
19. I am able to soothe my child when he/she is upset
20. I spend my time with my child doing what he/she likes to do.

Protective Factors Survey for Caregivers