Banana Splits 2017 Pre-survey
Hello boys and girls!
The purpose of this survey is for me to understand how you feel about divorce or separation and your family. There are no right or wrong answers. Please just answer truthfully from your heart.
What is your first name
What is your last name
What grade are you in?
I believe children can cause their parents' divorce or separation
Kids always cause the divorce or separation
Kids sometimes can cause the divorce or separation
Kids never cause parents to divorce or separate
I'm not sure ???
I could talk to the following people about how I am feeling: (check all that apply)
a grandparent or other family member
a teacher or school counselor
my pet or stuffed animal
I talk to myself
I don't have anyone that I could talk to
Your family is different than some of your friends whose biological mom and dad live in the same home. How does this make you feel?
I don't care if kids know about how my family is different
I feel like I don't want anybody to know about how my family is different
I only tell my best friend or very close friends who I really trust. I don't want others to know
I get teased because my family is different
yes I get teased
no I do not get teased
When I have sad or other difficult feelings, I can: (check all that apply)
journal or draw
take some deep breaths
talk to someone I trust
play video games
play sports or a physical activity like running, boxing, etc
go to a special place by myself
take a shower or a bath
I'm not sure what to do
i do something different than what is listed above
Spending time with and accepting step family members or a new person in my parents' life :
is not okay
I'm not certain how I feel about step family members
I don't have step family members
Since my parents have divorced or separated, I feel
Loved even more by my parents than I did before the divorce or separation
Loved about the same as I did before the divorce or separation
Loved less than I did before the divorce or separation
Like I'm not loved at all
When I think about my family I believe that
I get what I need from my family
I kinda get what I need from my family
I don't get what I need from my family
Check all of the boxes that you find really hard about having parents that don't live together
I miss my dad when I'm with my mom and I miss my mom when I'm with my dad
I don't get to see my mom
I don't get to see my dad
My family does not have as much money as we did before
I had to move out of my house
I had to move away from my school
I don't get to see some of my brothers or sisters as much
My parents argue all the time and can't get along
none of these
In the space provided below, tell me whatever you think I should know about you or your family that would help me support you in this group:
The End :)
Thank you for taking this survey. We are going to have fun together in Banana Splits Club!
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