JFCS: Parents Place Single Parent Survey

In what city do you reside?

Zip Code

Age

What is your relationship status?

Always Single
Formerly Married
Formerly Partnered
Separated
Widow/widower

What is your parenting arrangements?

Full time parent
I share parenting
I have no custody

What is your employment status?

Employed full time
Employed part time
Not Employed

What hours do you work?

Traditional (8 or 9 to 5)
Split shilt (11 to 7)
Graveyard (midnight to early AM)
Irregular
Other

if other, please describe:

What is your monthly income?

How many children do you have?

# of children newborn to 5:
# of children 6-13:
# of children 13+:

Religious Affiliation

Jewish
Not Jewish

What types of services
could be helpful to you?
(Please select only 3)

Parent Consultation:

In my home
At an agency

Parent support group with other single parents
Parenting classes
Co_parenting/Co_partner classes
A family mentor for strengthening family living skills>
Counseling
Time management
Budget planning/money management for me
Budget planning/money management for my children
Other

if other, please describe:

What time of day is best
for you to access services
(check all that apply)?

Mornings
Afternoons
Evenings
Weekends

What has affected your
use of services in the past?
(Please select only 3)

Agencies are not open during hours I could make use of the services
Costs are too high
No transportation
I have enough family and friend for support
I have not found programs that address my needs
I don't feel comfortable asking for help
Lack of childcare
Other

if other, please describe:

What is the best way for
you to find out about
programs and services?
(Please select 3 only)

Newspaper

which newspaper:

Synagogue or Church newsletters
Free Parent magazines
Radio
My Physician's office
My child's school
Coffee house bulletin boards
Recommendation of friends / family
Other

if other, please describe:

Thank you so much for your time. This information will be helpful to us in planning programming to meet your needs.

To thank you for your time Parents Place would like to offer you a 20% discount off your next Parents Place class. Coupons will be emailed upon receipt of the following contact information. (only name and email address is required.)

To be entered into the Parents Place database to receive information about our classes and programs, please fill out all of the following information.