Date Completed: ____ /____ /____
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
2-3 months ago
4-6 months ago
7-9 months ago
10-12 months ago
Over 1 year ago
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.
In my family, we talk about problems.
When we argue, my family listens to “both
sides of the story.”
In my family, we take time to listen to each
My family pulls together when things are
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.
I have others who will listen when I need to
talk about my problems.
When I am lonely, there are several people I
can talk to.
I would have no idea where to turn if my
family needed food or housing.
I wouldn’t know where to go for help if I had
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.
Child’s Age: ________
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.
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
20. I spend time with my child doing what
he/she likes to do.