FCSS Perinatal Mental Health Survey FCSS Perinatal Mental Health SurveyProgram Type PMH Peer Support PMH Zoom Groups Worker Email(Required) A confirmation message will be sent to this email address.Survey SelectionSurvey Type(Required) Initial Progress Post Survey Date(Required) Month Day Year Client InformationFirst Name(Required)Last Name(Required)Birthdate(Required) Month Day Year Gender(Required) Female Male Transgender Non-Binary Two-Spirit Other Prefer Not to Say Demographic QuestionsWhat Neighbourhood do you live in?(Required)First 3 Digits of your Postal Code?(Required)Language spoken most often at home:(Required) English French Indigenous Language Arabic Cantonese Dinka Farsi Hindi Korean Kurdish Mandarin Nuer Pashto Polish Punjabi Somali Spanish Tagalog Urdu Vietnam Other If other please list:Primary Population:(Required) Caucasian Chinese South Asian (India, Pakistani, Sri Lankan, etc.) African/Caribbean Filipino Latin American Southeast Asian (Vietnamese, Cambodian, Thai, Laotian, etc.) Arab/West Asian Korean Japanese Indigenous (First Nations, Métis, Inuit) Other Indigenous Identity(Required) First Nations (Status/Non-Status) Métis Inuk (Inuit) Other If other please list:Were you Born in Canada?(Required) Yes No Country of Birth(Required)Year of Arrival(Required)Marital Status(Required) Married Common Law Widowed Separated Single, Never Married Divorced Other Primary Income Source(Required) No Income Employment AISH Alberta Income Support Alberta Family Employment Tax Credit Alberta Child Benefit Canada Child Benefit Canada Pension Plan (CPP) Old Age Security (OAS) Guaranteed Income Supplement (GIS) Personal Private Pension/Savings/Trust Fund/Inheritance War Veterans Allowance (WVA) Workers Compensation (WCB) GST Rebate Employment Insurance (EI) Alternative Income Source/Parents Other Current Housing Situation(Required) Stable Housing Temporary Housing Couch Surfing Shelter No Shelter, Sleeping Rough Other Highest Grade Completed in School:(Required)Highest Level of Education Completed After High School:(Required) Not Applicable Apprenticeship/Trades Certificate Non-University/Degree/Diploma Bachelor’s Degree or Above AccessibilityDo you have any long-term (over 6 months):Difficulties with hearing, seeing, walking, climbing, or doing any similar activities? Select One:(Required) Yes, sometimes Yes, often No Emotional, psychological or mental health conditions (e.g., anxiety, depression, bipolar disorder, substance abuse, anorexia, etc.)? Select One:(Required) Yes, sometimes Yes, often No Cognitive difficulties such as learning, remembering, or concentrating, or doing any similar activities? Select One:(Required) Yes, sometimes Yes, often No HouseholdNumber of Adults in Household(Required)(18 or older)Number of Other People in Household(Required)(Under 18)Total of People in Household(Required)Social Support and Daily LivingHow often is each of the following kinds of support available to you if you need it:Someone to enjoy your time with? Select one:(Required) Never A little of the time Some of the time Most of the time Always Someone to turn to for suggestions about how to deal with a personal problem? Select one:(Required) Never A little of the time Some of the time Most of the time Always Someone to take you to the doctor if you needed it? Select one:(Required) Never A little of the time Some of the time Most of the time Always Someone to spend time with to get your mind off of things? Select one:(Required) Never A little of the time Some of the time Most of the time Always Someone to help with daily chores if you were unable to do it yourself? Select one:(Required) Never A little of the time Some of the time Most of the time Always Family Functioning – Parent/AdultWe would like to know about your family relationships. Please describe how often each of the following statements describes your family. Please do not leave any questions blank, answer the questions honestly. In times of crisis we can turn to each other for support. Select one:(Required) Never A little of the time Most of the time Always In our family we feel accepted for who we are. Select one:(Required) Never A little of the time Most of the time Always We are able to make decisions about how to solve problems. Select one:(Required) Never A little of the time Most of the time Always We don't get along well together. Select one:(Required) Never A little of the time Most of the time Always Drinking, drug use, or gambling is a source of tension or disagreement in our family. Select one:(Required) Never A little of the time Most of the time Always We feel hopeful about the future. Select one:(Required) Never A little of the time Most of the time Always In my family we talk to each other about the things that matter to us. Select one:(Required) Never A little of the time Most of the time Always FCSS Post-Survey – Satisfaction QuestionsWe would like to know about your experience with this FCSS funded program.Overall, I am satisfied with this FCSS funded program/service. Select one(Required) Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree Overall, I found this program easy to access (e.g., it was simple to find the programming, easy to register, the referral process was straight forward, etc.). Select one:(Required) Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree UntitledUntitledUntitledUntitledPost Title Untitled
