Caregiver Survey
Help us get to know your families and their needs! Please fill out questions as you feel comfortable, you are not required to answer a question if it makes you feel uncomfortable. The purpose of this survey is to get to know families and their needs the best we can. Your answers will be treated with a sensitive manner.
Which type of family are you?
Caregiver #1 Full Name
Your answer
Caregiver #2 Full Name
Your answer
Address
Your answer
Caregiver #1 Email
Your answer
Caregiver #2 Email
Your answer
Caregiver #1 Phone Number
Your answer
Caregiver #2 Phone Number
Your answer
Children's Names: Birth Date, Current Grade(+School if other than ZCS), if adopted/fostered/etc (+country if international adoption), year adopted/etc, race, special need/health condition (if applicable)
(ALL children in the household please, even biological children) Ex: John Smith: 01/01/2012, 1st grade, Adopted (international), Colombia, Adopted in 2016, Hispanic OR Sara Smith : 01/02/2010 , 3rd grade, Biological, Caucasion
Your answer
Agency for adoption,etc (if applicable)
Your answer
Church
Your answer
Is there anything specific that you/your family struggles with?
(Ex:food hoarding, embracing birth family, behavior issues, post adoption depression, etc)
Your answer
How do you feel your adopted/fostered/etc child/ren are doing?
(Have they experienced trauma prior to coming into your family and has this had any lasting effect? Do they seem comfortable at home and school? Are triggers or struggles daily, a few times a year, at milestone events , or never?)
Your answer
How do you feel your biological child/ren are doing? (if applicable)
(Do they seem to connect well with their adopted/fostered/etc siblings? Do they struggle with any complexities their sibling brings?)
Your answer
Do you feel currently supported as an adoptive/foster/other parent?
(Not at all)
(Completely)
In what ways do you feel you could be more supported?
(at school, in a support system, etc)
Your answer
Do you/your child receive support outside of school?
(ex: counseling, physical therapy, Medicaid, etc)
Your answer
In what ways has the school system helped your child?
(if applicable. ex: speech therapy, etc)
Your answer
Do you feel ZCS teachers/staff are sensitive to adoption/childhood trauma/race/ethnicity/etc?
Your answer
Would you/your family be interested in any of the following?
(please select all that apply. PLEASE note in the "other" section if you need to add any comments or other ideas!)
What days/times work best for your family for extra events?
Is there anything else you would like us to know?
We want to hear your ideas! Concerns, thoughts, anything that will help us support your family!
Your answer
Would you be willing to be a part of our team? If so, please specify what you would be willing to help with.
(anything from being a part of planning events, to helping with fundraising if needed, to volunteering to buy/bring in pizzas / chaperone a pizza party, being willing to walk alongside a family that has just recently adopted, etc)
Your answer
If you have any further questions or comments, please contact us at zcschoolmosaic@gmail.com
Thank you for taking the time to fill in this survey!
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