Please bookmark this page now so you can return to it to fill out the survey for the second time at the end of the program.
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ALL FIELDS MUST COMPLETED. Check here only if you are NOW STARTING the Parenting Wisely Program Check here only if you are FINISHED the Parenting Wisely Program Today's Date:
Name
First Last:
Address
Street: City: State: Zip:
Phone: E-mail (optional):
Sex: Please Select Female Male
Race: african-american latino white asian-american Please Select Race
Age Range: 18-25 25-30 30-35 35-40 40+ Please Select Age Range
How did you hear about this program? * Delaware County Library System East Side Neighborhood Connection Eternal Hope of Glory Christ Lutheran (PEPP) Holcomb Behavioral Health Systems Other Group/Organization Please Select *TIP: You must select an organization in order to receive the $25 incentive for completing the program.
PARENTING WISELY - PRE-TEST
During the past month, when you and your child have spent time talking or doing things together, how often did you:
a. Get angry at him or her
Please Select Answer 1-Always 2-Almost Always 3-Fairly Often 4-About Half the time 5-Not too often 6-Almost Never 7-Never
b. Let this child know you really care about him or her
Please Select Answer 1-Always 2-Almost Always 3-Fairly Often 4-About Half the time 5-Not too Often 6-Almost Never 7-Never
c. Shout or yell at this child because you were mad at him or her
d. Act loving and affectionate toward him or her
e. Let this child know that you appreciate him or her, his or her ideas or things he or she does
f. Yell, insult or swear at him/her when you disagreed
g. When this child does something wrong, how often do you lose your temper and yell at him or her
Having trouble with this page? Please let use know! E-mail info@holcombprevention.org or call 484-444-0412 - Remember - "We're Here to Help"
