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Questionnaire for JOM Parents and Guardians
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* Indicates required question
How many school-age children do you have?
*
Your answer
What is the age of your child(ren)? Choose all that apply:
*
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
What school does your child(ren) attend? List all that apply:
*
Your answer
Would you be interested if in-school therapy were offered to your child?
*
Yes
No
Maybe
What activities do you have planned this Summer with your child(ren)?
*
Your answer
What are some of your child’s educational needs?
*
Your answer
What are some educational assistance programs you would like offered this Summer to help your child to stay on track?
*
Tutoring
Educational Resources
Activities
Summer School
Library Program
Other:
Have you seen an increase in your child’s:
1 = None 2 = Some 3 = Moderate 4 = Significant
Depression
*
None
1
2
3
4
Significant
Anger
*
None
1
2
3
4
Significant
Frustration
*
None
1
2
3
4
Significant
Poor Peer Interaction
*
None
1
2
3
4
Significant
Anxiety
*
None
1
2
3
4
Significant
Isolation
*
None
1
2
3
4
Significant
Substance Use
*
None
1
2
3
4
Significant
Negativity
*
None
1
2
3
4
Significant
Would you be interested in a family night at the community center or department of health facility?
*
Yes
No
Maybe
Would you like some trainings on “Surviving kids and raising adults”?
*
Yes
No
Maybe
Have you had any significant losses in the past year?
*
Yes
No
What has been your biggest frustration this past year with your child(ren)?
*
Your answer
If you had the opportunity for an elder to speak on mentoring topics to your child(ren) would be interested?
*
Yes
No
Maybe
What are some of the topics you would like discussed?
*
Your answer
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