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2015
August
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Parent Questionnaire
Parent Questionnaire
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Exit Survey
Thank you for agreeing to complete this questionnaire. Please consider each question and think of how each question relates to you.
Please enter the reference number provided with your information sheet.
Below you will find a list of statements. Please rate how true each statement is for you by clicking below.
never true
very seldom true
seldom true
sometimes true
frequently true
almost always true
always true
My painful experiences and memories make it difficult for me to live a life that I would value.
I'm afraid of my feelings
I worry about not being able to control my worries and feelings
My painful feelings stop me having a fulfilling life
Emotions cause problems in my life
It seems like most people are handling their lives better than I am.
Worries get in the way of my success.
Below is a collection of statements about your everyday experience. Using the scale below, please indicate how frequently or infrequently you’ve had each experience in the last month. Please answer according to what really reflects your experience rather than what you think your experience should be.
Never or very rarely true
Not often true
Sometimes true, sometimes not true
Often true
Very often or always true
I’m good at finding the words to describe my feelings.
I can easily put my beliefs, opinions, and expectations into words.
I watch my feelings without getting carried away by them.
I tell myself that I shouldn’t be feeling the way I’m feeling.
It’s hard for me to find the words to describe what I’m thinking.
I pay attention to physical experiences, such as the wind in my hair or the sun on my face.
I make judgments about whether my thoughts are good or bad.
I find it difficult to stay focused on what’s happening in the present moment.
When I have distressing thoughts or images, I don’t let myself be carried away by them.
Generally, I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing.
Never or very rarely true
Not often true
Sometimes true, sometimes not true
Often true
Very often or always true
When I feel something in my body, it’s hard for me to find the right words to describe
It seems I am running on automatic without much awareness of what I’m doing.
When I have distressing thoughts or images, I feel calm soon after.
I tell myself I shouldn’t be thinking the way I’m thinking.
I notice the smells and aromas of things.
Even when I’m feeling terribly upset, I can find a way to put it into words.
I rush through activities without being really attentive to them.
When I have distressing thoughts or images, I can just notice them without reacting.
I think some of my emotions are bad or inappropriate and I shouldn’t feel them.
I notice visual elements in art or nature, such as colours, shapes, textures, or patterns of lights and shadow.
When I have distressing thoughts or images, I just notice them and let them go.
I do jobs or tasks automatically without being aware of what I’m doing.
I find myself doing things without paying attention.
I disapprove of myself when I have illogical ideas.
What age are you?
What age is your child?
Is your child...
Male
Female
What is your relationship to the child?
Mother
Father
Grandmother
Grandfather
Guardian
Other
How would you describe your ethnic origin?
How many children live at home?
1
2
3
4
5
5+
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