Clark County Family Court Division
Family Solutions Inc.

Parenting Partners’ Participant Survey

Participant Survey (Confidential)

Family Court Services is very interested in your opinions about our providers’ services. We would greatly appreciate it if you would take some time to fill out the following questionnaire. You can be sure that your opinions do count. Thank you!

Date(Required)

State

Zip / Postal Code(Required)

County(Required)

Include "County"

First Name(Required)

Last Name(Required)

Email(Required)

Case Number

Who referred you to our seminar? (Please √ Check one and PRINT their name)(Required)

Attorney

Paralegal

The Court/Judge/Self-Help Center

Name of referrer(Required)

Legal Representation(Required)

We both have an attorney.

Only one of us has an attorney.

Neither of us has an attorney.

Other

Your Relationship to Child(Required)

Mother

Father

Other

Which one of these are you?(Required)

Petitioner

Respondent

Co-Petitioner

How many biological children do you share with the other parent in the case?(Required)

Your Gender(Required)

Male

Female

Domestic Violence(Required)

A current domestic violence restraining order is in place.

A domestic violence restraining order was in place previously.

There has never been a domestic violence restraining order but I have safety concerns.

There has never been a domestic violence restraining order and I have no safety concerns.

Your Race and Ethnicity(Required)

Caucasian/European American

African American

Hispanic

Native American

Asian/Pacific Islander

Other

Your Education(Required)

Grades 0-8th

Grades 9-11

High School Graduate

Technical School Graduate/GED

Some College (Community College - AA)

College Graduate (BA/BS)

Post-Graduate School (MA/PhD/Professional Degree)

Marital Status(Required)

Remarried

Living with a partner

Live alone

Still married

Other

Custody Status(Required)

I have custody of the children.

The other parent has custody of the children.

We both have custody of the children.

Custody has not been established

Other

Household Income(Required)

Under $20,000

$20,000 to $29,000

$30,000 to $39,000

$40,000 to $49,000

$50,000 to $59,000

$60,000 to $69,000

$70,000 or over

1. The following questions refer to you, the other parent who is involved in the current court action with you, and your mutual child or children. Mark the box that best describes your situation:(Required)

Mark the box that describes how much you agree or disagree with the following statements:

	Always	Often	Rarely	Never	Doesn't Apply
a. Do you feel friendly toward your former partner?
b. Do your children feel friendly toward your former partner?
c. Do you find you and your former partner disagree in front of the children?
d. Do the children take sides in disagreements between you and your former partner?
e. Does your former partner say things about you to the children that you don't want them to hear?
f. Do you say things about your former partner to the children that he/she wouldn't want them to hear?
g. Are pick-ups and drop-offs of the children between you and your former partner a difficult time?

2. How often in the past month have:(Required)

	Always	Often	Rarely	Never	Doesn't Apply
a. Your children seen their parents arguing or being tense during a transition?
b. You asked your children to carry messages to the other parent?
c. You talked bad about the other parent in front of your children?
d. Your children been upset about the conflict between you and the other parent?
e. You talked to your children about money issues or concerns about the other parent?
f. You asked your children questions about the other parent's personal life?

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
3. Overall I found this seminar/course to be helpful.
4. I learned some specific skills that will help me better communicate with my co-parent.
5. I am confident that I can use these skills to improve the relationship with my co-parent.
6. I learned something new about how my children are affected by conflict.
7. The course covered important information and topics which were presented in a clear and professional manner.

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
8. I learned about the benefits of mediation and other ways of solving problems instead of going to court

10. What were the most interesting or important things you learned in the seminar/course?(Required)

11. If you have a "BURNING" question that you want answered on our Facebook page or blog, please ask here:(OPTIONAL)

Do you want to stay in contact? Please print Email address (OPTIONAL)

	Very Likely	Somewhat Likely	Neutral	Somewhat Unlikely	Very Unlikely
9. How likely are you to go to court in the next two years to solve a problem?

Clark County Family Court Division Family Solutions Inc.

Parenting Partners’ Participant Survey

Participant Survey (Confidential)

Clark County Family Court Division
Family Solutions Inc.