Parent Information
Your Sex Male Female
Race/Ethnicity Native American or Alaskan Native Asian African American African Nationals/Caribbean Islanders Hispanic or Latino Middle Eastern Native Hawaiian/Pacific Islanders White (Non Hispanic/European American) Multi-racial
Marital Status: Married Partnered Single Divorced Widowed Separated
Family Housing Own Rent Shared housing with relatives/friends Temporary (shelter, temporary with friends/relatives) Homeless
Family Income $0-$10,000 $10,001-$20,000 $20,001-$30,000 $30,001-$40,000 $40,001-$50,000 more than $50,001
Highest Level of Education Elementary or junior high school Some high school High school diploma or GED Trade/Vocational Training Some college 2-year college degree (Associate’s) 4-year college degree (Bachelor’s) Master’s degree PhD or other advanced degree
  Which, if any, of the following do you currently receive? (Check all that apply) Food StampsMedicaid (State Health Insurance)Earned Income Tax CreditTANFHead Start/Early Head Start ServicesNone of the above
Please tell us about the children living in your household.
Sex of 1st child Male Female
Your Relationship to child Birth parent Adoptive parent Grand/Great Grandparent Sibling Other relative Foster-parent other
Sex of 2nd child Male Female
Sex of 3rd child Male Female
Sex of 4th child Male Female
Never
Very Rarely
Rarely
About Half the Time
Frequently
Very Frequently
Always
In my family, we talk about problems.
When we argue, my family listens to "both sides of the story."
In my family, we take time to listen to each other.
My family pulls together when things are stressful
My family is able to solve our problems.
I praise my child when he/she behaves well.
When I discipline my child, I lose control.
I am happy being with my child.
My child and I are very close to each other.
I am able to soothe my child when he/she is upset.
I spend time with my child doing what he/she likes to do.
Strongly Disagree
Mostly Disagree
Slighty Disagree
Neutral
Slighty Agree
Mostly Agree
Strongly Agree
I have others who will listen when I need to talk about my problems.
When I am lonely, there are several people I can talk to.
I would have no idea where to turn if my family needed food or housing.
I wouldn’t know where to go for help if I had trouble making ends meet.
If there is a crisis, I have others I can talk to.
If I needed help finding a job, I wouldn’t know where to go for help.
There are many times when I don’t know what to do as a parent.
I know how to help my child learn.
My child misbehaves just to upset me.
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Which location are you interested in Freehold Howell Manalapan