Name
*
First Name
Last Name
Phone Number
*
(###)
###
####
Email
*
What is your cultural heritage?
*
Indigenous
Francophone
Newcomer
None of the Above
Prefer not to answer
If you are a newcomer, how long have you been in Canada?
Less than 3 years
More than 3 years
Are you a parent or caregiver?
*
Yes
No
How many additional adults will be participating with you in this program?
*
Which community do you live in?
*
Fort McKay
Fort McMurray
Anzac
Fort McMurray First Nations 468
Janvier
Chard
Conklin
Other community in Wood Buffalo
Outside Wood Buffalo
How many children do you care for?
*
Child 1 birth date
*
MM
DD
YYYY
Child 2 birth date
MM
DD
YYYY
Child 3 birth date
MM
DD
YYYY
Child 4 birth date
MM
DD
YYYY
Child 5 birth date
MM
DD
YYYY
Child 6 birth date
MM
DD
YYYY
If applicable, how many children are newcomers?
If applicable, how many children have been in Canada less than 3 years?
If applicable, how many children are Francophone?
If applicable, how many children are Indigenous?
2. When we argue, my family listens to "both sides of the story".
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always
3. In my family we take time to listen to each other.
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always
4. My family pulls together when things are stressful.
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always
5. My family is able to solve our problems.
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always
7. When I am lonely, there are several people I can talk to.
*
1 Strongly Disagree
2 Mostly Disagree
3 Slightly Disagree
4 Neutral
5 Slightly Agree
6 Mostly Agree
7 Strongly Agree
8. I would have no idea where to turn if my family needed food or housing.
*
1 Strongly Disagree
2 Mostly Disagree
3 Slightly Disagree
4 Neutral
5 Slightly Agree
6 Mostly Agree
7 Strongly Agree
9. I wouldn't know where to go for help if I had trouble making ends meet.
*
1 Strongly Disagree
2 Mostly Disagree
3 Slightly Disagree
4 Neutral
5 Slightly Agree
6 Mostly Agree
7 Strongly Agree
10. If there is a crisis, I have others I can talk to.
*
1 Strongly Disagree
2 Mostly Disagree
3 Slightly Disagree
4 Neutral
5 Slightly Agree
6 Mostly Agree
7 Strongly Agree
11. If I needed help finding a job, I wouldn't know where to go for help.
*
1 Strongly Disagree
2 Mostly Disagree
3 Slightly Disagree
4 Neutral
5 Slightly Agree
6 Mostly Agree
7 Strongly Agree
Child's date of birth
*
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.
MM
DD
YYYY
12. There are many times when I don't know what to do as a parent.
*
1 Strongly Disagree
2 Mostly Disagree
3 Slightly Disagree
4 Neutral
5 Slightly Agree
6 Mostly Agree
7 Strongly Agree
13. I know how to help my child learn.
*
1 Strongly Disagree
2 Mostly Disagree
3 Slightly Disagree
4 Neutral
5 Slightly Agree
6 Mostly Agree
7 Strongly Agree
14. My child misbehaves just to upset me.
*
1 Strongly Disagree
2 Mostly Disagree
3 Slightly Disagree
4 Neutral
5 Slightly Agree
6 Mostly Agree
7 Strongly Agree
16. When I discipline my child, I lose control.
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always
17. I am happy being with my child.
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always
18. My child and I are very close to eachother.
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always
19. I am able to soothe my child when he/she is upset.
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always
20. I spend time with my child doing what he/she likes to do.
*
1 Never
2 Very Rarely
3 Rarely
4 About Half the Time
5 Frequently
6 Very Frequently
7 Always