FCSS PMH Survey - Families Matter

FCSS Perinatal Mental Health Survey

Program Type

PMH Peer Support

PMH Zoom Groups

Worker Email(Required)

A confirmation message will be sent to this email address.

Survey Selection

Survey Type(Required)

Initial

Progress

Post

Survey Date(Required)

Client Information

First Name(Required)

Last Name(Required)

Birthdate(Required)

Gender(Required)

Demographic Questions

What Neighbourhood do you live in?(Required)

First 3 Digits of your Postal Code?(Required)

Language spoken most often at home:(Required)

Primary Population:(Required)

Indigenous Identity(Required)

First Nations (Status/Non-Status)

Métis

Inuk (Inuit)

Other

Were you Born in Canada?(Required)

Yes

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)

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

Accessibility

Do you have any long-term (over 6 months):

Difficulties with hearing, seeing, walking, climbing, or doing any similar activities?(Required)

Emotional, psychological or mental health conditions (e.g., anxiety, depression, bipolar disorder, substance abuse, anorexia, etc.)?(Required)

Cognitive difficulties such as learning, remembering, or concentrating, or doing any similar activities?(Required)

Household

Number 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 Living

How often is each of the following kinds of support available to you if you need it:

Someone to enjoy your time with?(Required)

Someone to turn to for suggestions about how to deal with a personal problem?(Required)

Someone to take you to the doctor if you needed it?(Required)

Someone to spend time with to get your mind off of things?(Required)

Someone to help with daily chores if you were unable to do it yourself?(Required)

Family Functioning – Parent/Adult

We 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.(Required)

In our family we feel accepted for who we are.(Required)

We are able to make decisions about how to solve problems.(Required)

We don't get along well together.(Required)

Drinking, drug use, or gambling is a source of tension or disagreement in our family.(Required)

We feel hopeful about the future.(Required)

In my family we talk to each other about the things that matter to us.(Required)

FCSS Post-Survey – Satisfaction Questions

We would like to know about your experience with this FCSS funded program.

Overall, I am satisfied with this FCSS funded program/service.(Required)

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.).(Required)