CLARK COUNTY PARENTS FOR PARENT DEPENDENCY 101 PRE-SURVEY
Your Initials:
*
Email
*
example@example.com
Date of Dependency 101 class:
*
-
Month
-
Day
Year
Date
Is this your first dependency?
*
Yes
No
Your gender
*
Women
Man
Non-binary
Prefer not to say
Do you consider yourself Hispanic or Latino?
*
Yes
No
Please check one:
*
White/Caucasian
Black or African American
Asian or Asian American
American Indian or Alaskan Native
Native Hawaiian or other Pacific Islander
Biracial/Multiracial
Other
Your Age
*
Under 18
18-24
25-34
35-44
45-54
55 and over
Please indicate your current housing situation:
*
Living with friends or relatives
Homeless ( on the streets, in car)
Couchsurfing (Frequent moves from place to place)
Inpatient Treatment
Subsidized Housing
Emergency shelter
Self-pay motel/motel voucher
Transitional housing
Non subsidized housing or rental
Work release
Other
Do you currently receive TANF?
*
Yes
No
What was your family's total income last month (past 30 days)?
*
No income
$1-250
$250-500
$501-1000
$1001-1500
$1501-2000
$2001+
What is your highest level of education?
*
Less than high school?
High School/GED
Some College
2 year degree (Associates)
4 year degree (BA, BS)
Masters
Doctorate
How long has your current dependency case been open?
*
Less than 3 months
3-6 months
6-12 months
Over 12 months
Not sure
I realize I need some help to make sure my kids have what they need. (1: Disagree Strongly. 5: Strongly Agree.)
*
1
2
3
4
5
I believe my family will get help we really need from CPS (1: Disagree Strongly. 5: Strongly Agree.)
*
1
2
3
4
5
I feel like I can trust CPS to be fair and see my side of things. (1: Disagree Strongly. 5: Strongly Agree.)
*
1
2
3
4
5
I understand the roles of the professionals (people working on my case) involved in the child welfare system. (1: Disagree Strongly. 5: Strongly Agree.)
*
1
2
3
4
5
I believe there are things I can do so that the Court will return my children to me (1: Disagree Strongly. 5: Strongly Agree.)
*
1
2
3
4
5
Submit
Should be Empty: