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MentoringMamma Parenting Assessment
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* Indicates required question
Email
*
Your email
Name and Surname
*
Your answer
What is your marital status?
*
Married
Divorced
Seperated
Single
In a relationship
How long has your child been self harming?
*
Your answer
Is he/she receiving professional help?
*
yes
No
Other:
Are you getting help in the form of counselling or other services for your mental health?
*
Yes
No
Has your child experienced any childhood trauma?
*
Yes
No
Did you experience any childhood trauma?
*
Yes
No
SELF CARE QUESTIONS:
Does your child have a self care routine?
*
Yes
No
Do you have a self care routine?
*
Yes
No
Does the family generally eat a healthy diet?
*
Yes
No
Do you keep snacks and other treats in the house accessible to your children?
*
Yes
No
Do you consume carbonated drinks regularly?
*
Yes
No
Does your child drink tea or coffee or other stimulants like cola?
*
Yes
No
Does your child crave sugary foods?
*
Yes
No
How many hours a night does your child sleep?
*
Your answer
How many hours a night do you sleep?
*
Your answer
What is your morning routine?
*
Your answer
What is your child's morning routine?
*
Your answer
Does the family take part in sport or exercise?
*
Yes
No
Does the family take time out together to relax, ie walk, watch TV, gardening etc?
*
Yes
No
Does your child have a regular bedtime?
*
Yes
No
What is your bedtime routine?
*
Your answer
What is your child's bedtime routine?
*
Your answer
TECHNOLOGY QUESTIONS:
Are there any boundaries around technology use in the home?
*
Yes
No
Does your child have a phone agreement in place - verbally or written?
*
Yes
No
Does your child have access to social media platforms?
*
Yes
No
Does your child sleep with their phone in their bedroom?
*
Yes
No
Do you sleep with your phone in your bedroom?
*
Yes
No
HOME ENVIRONMENT
Does your child have their own bedroom?
*
Yes
No
Does your child have duties or chores and responsibilities at home?
*
Yes
No
Are their step children or non biological siblings in the home?
*
Yes
No
Do you have a family pet?
*
Yes
No
Does your child have a solid group of friends?
*
Yes
No
Does your child have a best friend?
*
Yes
No
Does your child have a hobby?
*
Yes
No
Does your child struggle at school academically?
*
Yes
No
Do you live near family members of friends that share your family values?
*
Yes
No
Do you regularly take family vacations together?
Yes
No
Clear selection
Do you have regular family fun days out?
*
Yes
No
EMOTIONAL INTELLIGENCE QUESTIONS
Is your child able to name and express their emotions?
*
Yes
No
Does your child have emotional meltdowns?
*
Yes
No
Have you given your child alternative options to expression other than self harm?
*
Yes
No
Does your child have stress relief activities?
*
Yes
No
Is your child able to recognise when they feel stressed?
*
Yes
No
A copy of your responses will be emailed to the address you provided.
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