FCSS PMH Survey

FCSS Perinatal Mental Health Survey

Worker Email(Required)

A confirmation message will be sent to this email address.

Survey Selection

Client Information

First Name(Required)

Last Name(Required)

Demographic Questions

What Neighbourhood do you live in?(Required)

First 3 Digits of your Postal Code?(Required)

Country of Birth(Required)

Year of Arrival(Required)

Highest Grade Completed in School:(Required)

Accessibility

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

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

Yes, Sometimes	Yes, Often	No

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

Yes, Sometimes	Yes, Often	No

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

Yes, Sometimes	Yes, Often	No

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)

Never	A Little of the Time	Most of the Time	Always

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

Never	A Little of the Time	Most of the Time	Always

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

Never	A Little of the Time	Most of the Time	Always

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

Never	A Little of the Time	Most of the Time	Always

We feel hopeful about the future.(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.(Required)

Never	A Little of the Time	Most of the Time	Always

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)