Protective Factors Survey Template
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1Date Completed: ____ /____ /____
English
Protective Factors Survey
When was your first visit to the FRC?
How many times have you visited the FRC?
Which FRC Workshops have you attended
(check all that apply)?
Within the past month
1-3 times
2-3 months ago
4-6 times
Abriendo Puertas
4-6 months ago
7-9 times
SEEDS
7-9 months ago
10-12 times
Triple P
10-12 months ago
13-15 times
Arts Enrichment
Over 1 year ago
16+ times
Other: _______________________
Over 2 years ago
How many children do you have under the age of 6? ________
Part 1. Please MARK “X” in the answer that best describes how often the statements are true for you or your family.
Very
Very
About half
Never
Rarely
Frequently
Always
Rarely
the time
Frequently
1.
In my family, we talk about problems.
When we argue, my family listens to “both
2.
sides of the story.”
In my family, we take time to listen to each
3.
other.
My family pulls together when things are
4.
stressful.
5.
My family is able to solve our problems.
Part 2. Please MARK “X” in the answer that best describes how much you agree or disagree with the statement.
Strongly
Mostly
Slightly
Slightly
Mostly
Strongly
Neutral
Disagree
Disagree
Disagree
Agree
Agree
Agree
I have others who will listen when I need to
6.
talk about my problems.
When I am lonely, there are several people I
7.
can talk to.
I would have no idea where to turn if my
8.
family needed food or housing.
I wouldn’t know where to go for help if I had
9.
trouble making ends meet.
10. If there is a crisis, I have others I can talk to.
11. If I needed help finding a job, I wouldn’t know
where to go for help.
Part 3. 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. Please write down the child’s age or date of birth.
Strongly
Mostly
Slightly
Slightly
Mostly
Strongly
Child’s Age: ________
Neutral
Disagree
Disagree
Disagree
Agree
Agree
Agree
12. There are many times when I don’t know what
to do as a parent.
13. I know how to help my child learn.
14. My child misbehaves just to upset me.
Part 4. Please tell us how often each of the following happens in your family.
Very
Very
About half
Never
Rarely
Frequently
Always
Rarely
the time
Frequently
15. I praise my child when he/she behaves well.
16. When I discipline my child, I lose control.
17. I am happy being with my child.
18. My child and I are very close to each other.
19. I am able to soothe my child when he/she is
upset.
20. I spend time with my child doing what
he/she likes to do.
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