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Who's In Charge - Pre-group Questionnaire

Please complete the following questionnaire to provide a picture of what life is like for you at this time.

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Date of session *

Your Name

First

Last

Your Postcode

Your Email

Contact number

Please tell us about the child whose behaviour is causing you the most concern.

Age of the Child *

Do they live with you? *

How many additional children are in the family *

Please provide the details of up to 5 additional children in the family

Age of Child 2 *

Age of Child 3 *

Age of Child 4 *

Age of Child 5 *

Age of Child 6 *

Does child 2 live with you? *

Does child 3 live with you? *

Does child 4 live with you? *

Does child 5 live with you? *

Does child 6 live with you? *

Do you have a partner that lives with you? *

Is the partner the natural parent of the child you are most concerned about ? *

Is there anyone else that lives with you ? *

Does the child have contact with their natural parent? *

Please provide their relationship to you and your child/ children ?

For each of the following questions please tell us how often, in the last 2 months (or the last 2 months you were together) have these behaviours happened to YOU

My child has hit ME *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has thrown things at ME *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has pushed or grabbed at ME *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has yelled at ME *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has verbally abused ME *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has destroyed MY property *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has displayed other violent or abusive behaviour towards ME *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

For each of the following questions please tell us how often, in the last 2 months (or the last 2 months you were together) have these behaviours happened to YOUR PARTNER

My child has hit my PARTNER *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has thrown things at my PARTNER *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has pushed or grabbed at my PARTNER *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has yelled at my PARTNER *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has verbally abused my PARTNER *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has destroyed my PARTNERS property *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has displayed other violent or abusive behaviour towards my PARTNER *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

For each of the following questions please tell us how often, in the last 2 months (or the last 2 months you were together) have these behaviours happened to the child's SIBLINGS

My child has hit their SIBLINGS *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has thrown things at their SIBLINGS *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has pushed or grabbed at their SIBLINGS *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has yelled at their SIBLINGS *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has verbally abused their SIBLINGS *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has displayed other violent or abusive behaviour towards their SIBLINGS *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

My child has destroyed their SIBLINGS property *

Never
Once or Twice
A few Times
Once or Twice a week
Daily or Almost Daily

The following statements focus on the impact of your child’s behaviour on you.

I feel able to cope with my child's behaviour *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I think things are getting better *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I feel stressed and/or anxious *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I feel guilty about my child’s behaviour *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I feel depressed or very unhappy *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I feel my health is suffering *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

I have good support over this issue. *

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

How long has your child been using abusive behaviour ? *

Please provide the following Additional Information about you and your child

Does your child have a diagnosed condition, for example a disability or ADHD ?

Please share with us what this is.

Has your child been abused in the past?

Has your child witnessed domestic violence?

How would you describe your style of parenting? (Please tick all that apply)

Strict
Firm
Controlling
Democratic
Loving
Traditional
Easy-going
Average
Hands-off
Fair
Indulgent
Other

Please share with us your parenting style

How would you describe the work YOU do, or YOUR occupation

How would you describe the work YOUR PARTNER does, or THEIR occupation

Consent

All information collected in this feedback questionnaire is anonymous unless you have chosen to provide your contact details, however we would like your consent for Suffolk Family Carers to hold it *