2026 Palliative Parenting Study Interest
The purpose of this questionnaire is submit preliminary interest to participate in the CMHRC Palliative Parenting study. This short survey will help us understand your interest and determine eligibility. Participation is voluntary and at no cost to study participants. You will receive an follow-up email from admin@cmhrc.org with information about next steps.
Name of Person Filling Out This Form
*
First Name
Last Name
Email of Person Filling Out This Form
*
example@example.com
Phone Number of Person Filling Out This Form
*
Please enter a valid phone number.
Format: (000) 000-0000.
I am a parent or caregiver.
Yes
No
Other
I take care of the following number of children
1-3
4-6
7 or more
The children in my care are aged (check all that apply)
5 years old or younger
6-9 years old
10-13 years old
14-17 years old
18-20 years old
21 years old or older
The child in my care who I am taking this course for is aged (check all that apply)
5 years old or younger
6 years old
7-11 years old
12-17 years old
18 years old or older
One or more of the children I take care of have mental health or behavioral challenges.
*
Yes
No
Unsure
Other
The study will require online attendance to the class one evening each week for ten weeks in a row. Are you comfortable with this commitment?
*
Yes
No
Unsure
Other
The study will require filling out several forms before you begin the course, after you complete the course, and again six months later. Are you comfortable with this commitment?
*
Yes
No
Unsure
Other
The study will require completing daily tracking of behaviors and symptoms. Are you comfortable with this commitment?
*
Yes
No
Unsure
Other
The study requires participants have access to a computer to use Zoom as well as other online software/apps. Do you have access to a computer to take the course?
*
Yes
No
Unsure
Other
How interested are you in participating in this study?
*
Very interested
Somewhat interested
Neutral
Slightly interested
Not interested
Would you be willing to participate if you are eligible?
*
Yes
No
Unsure
Other
What motivates you to consider participating? (Select all that apply)
*
Interest in the topic
Contributing to research
Learning something new
Helping others
Experiencing benefit for my family
Other
None of the above
Have you participated in a similar study before?
*
Yes
No
Unsure
Other
What concerns, if any, might prevent you from participating? (select all that apply)
*
Time commitment
Privacy/confidentiality
Scheduling
Topic sensitivity
None
Other
I have been told by a professional - or I suspect - my child(ren) has one or more of the following mental health conditions. (select all that apply)
*
Attention Deficit Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder (ASD)
Bipolar Disorder (types include: Type I, Type II, and Unspecified)
Cyclothymic Disorder
Disruptive Mood Dysregulation Disorder (DMDD)
Generalized Anxiety Disorder
Major Depressive Disorder
Persistent Depressive Disorder
Obsessive Compulsive Disorder
Oppositional Defiant Disorder
Panic Disorder
Post Traumatic Stress Disorder (PTSD or Complex PTSD)
Reactive Attachment Disorder (RAD)
Separation Anxiety Disorder
Social Anxiety Disorder
Thermoregulatory Sleep Dysregulation Disorder (aka FOH)
Unspecified Anxiety Disorder
Unspecified Mood Disorder
None of the above (specify below if possible)
Participant family has access to a medical professionals for ongoing mental and physical healthcare?
*
Yes
No
Unsure
Child(ren) in the household were adopted.
*
Yes
No
Unsure
Child(ren) in the household were adopted from foster care.
*
Yes
No
Unsure
Child(ren) in the household are currently in foster care.
*
Yes
No
Unsure
I live in this state in the United States:
blanks
I live in this state in the United States
*
If you have answered "unsure" to any of the above questions, please provide a brief explanation below:
How did you learn about the Palliative Parenting study?
*
Facebook
Instagram
Newsletter
Friend or family member
Mental health professional
If you selected "mental health professional", please share with us which provider shared the information with you.
I am aged 18 or older and I would like to submit myself to be considered for participation.
*
Yes
No
Unsure
Other
I give my consent to be contacted by CMHRC via email or phone.
*
Yes
No
I understand that all survey responses are kept confidential and stored in CMHRC's private Palliative Parenting study database. Prospective parents/caregivers that do not qualify for study participation will be offered a spot in a separate non-study based program with the same content. The information collected in this survey will not be shared outside of CMHRC and research staff.
*
Yes
No
I give my permission for my answers to this survey to be stored by CMHRC in order to communicate directly with me when new opportunities to participate in research or other programs arise.
*
Yes
No
Submit
Should be Empty: