Safe Passage  |  Parent Survey
This survey takes only a few minutes to complete, but the impact is timeless. Your feedback enables us to improve and fund services to you and others like you.  Your candid response to these questions is valued and appreciated.

Thank you for taking the time to complete this survey! We truly love your family.

From the bottom of our hearts,

Safe Passage



Please note: Our surveys are designed to eliminate personally identifying information. Should we use this information to report our impact, we will redact your name and any personally identifying information that you might provide in the “open answer” sections.
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Email *
First and Last Name (Person filling out form) *
Relationship to Youth *
Youth's First and Last Name *
Youth's Date of Birth *
Youth's Ethnicity *
Indicate the frequency with which you have observed the following behaviors exhibited by your child. *
Unsure
Never
Sometimes
Often
Very often
Running away
Lashing out verbally
Lashing out physically
Emotional swings
Lying
Keeping secrets
Manipulating others
Talking to strangers online
Meeting up with strangers they met online
Sending sexual videos or images
Selling sexual videos or images for money or drugs
Posting provocative content online
Selling body for sex
Petty theft (i.e. cosmetics and snacks)
Serious theft (i.e. drugs, electronics, money)
Self isolation
Verbally tears down family members
Skipping school
Self-harm
Drinking
Drugs
Sleeping with strangers
Vandalism
Property destruction
Disrespect
Sneaking out
Stubborn
Indicate the frequency with which you have observed the following in your child. *
Never
Sometimes
Neutral
Often
Very often
Anger
Loneliness
Neglect
Confusion
Misunderstood
Depressed / sad
Anxious
Irritable
Fear / afraid
Shame
Jealous
Stressed
Paranoid
Unsettled
Rage
Grief
Melancholy
Regret
Bored
Remorse
Tired
Restless
Bitter
Overlooked
Unhappy
Heartbroken
Insecure
Your personal feelings
Please indicate the frequency of the following feelings you have experienced regarding your child. *
Never
Sometimes
Neutral
Often
Very often
Depressed
Hopeless
Confused
Ready to give up as a parent
Ready to give up hope for my child
Ready to let my child go / leave / walk away
Like there were no specialized services to help
Pushed through system but not helped
Lacking support
Unheard / Screaming for help and no response
Scared for my child
Broken hearted
Overwhelmed
Out of options
Exhausted
Incapable of helping my child
Angry*
I am angry at ...
Impact of Previous Services
Please rate the following services your child has recently received from law enforcement, victim advocates, group homes, mental/psychological institutions, medical or other providers. *
N/A
Negative impact (made situation worse)
No impact
Positive impact
High impact
Counseling
Interview / Forensic Interview
Advocacy
Inpatient Services
Outpatient Services
Case Management
Mentoring (Safe Passage or other)
Guardian Ad Litem
History and Goals
In your own words, how would you describe your current situation and how we can best be of service to you and your child? *
What results would you like to see at the end of this mentorship? *
What goals do you have for yourself during the time your child participates in Safe Passage’s Mentorship program?
Please describe the things your child is good at or enjoys doing?
As a parent, for my own journey, [from Safe Passage staff] I would like to receive...
Clear selection
What else do you think we should know in order to best serve you, your child and your family? *
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