Addressing Substance Use Disorders Among Families Involved with the Child Welfare System: A Cross-Agency Collaboration

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Parent Demographic Form
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Please provide some information about yourself by completing this questionnaire. We will not report any of your responses by name. Thank you.
BACKGROUND
    1. In what county do you currently live?

____________________________________________
    2. Do you currently describe yourself as male, female or transgender
    • Male
    • Female
    • Transgender
    • None of these
    3. Would you describe yourself as Hispanic or Latino?
    • Yes
    • No
    4. How would you describe your racial background? Select all that apply.
    • American Indian or Alaska Native
    • Asian
    • Black or African American
    • Native Hawaiian or Other Pacific Islander
    • White
    5. What is your current marital status?
    • Single
    • Married
    • Living with someone
    • Separated
    • Divorced
    • Widowed
    6. How many children under the age of 18 do you have?
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6 or more
    7. How many of these children live with you full time
    • 1
    • 2
    • 3
    • 4
    • 5
    • 6 or more
    8. What is the highest education level completed? Select one.

    • 11th grade or less
    • 12th grade but no high school diploma
    • High school diploma or GED
    • Some college or technical school
    • Associate’s degree
    • Bachelor’s degree
    • Master’s degree
    • Doctoral degree
    • Professional degree (MD, JD, etc.)
    9. What is your current employment status
    • Full-time employment for wages
    • Part-time employment for wages
    • Self-employed for wages
    • Presently not employed outside the home, looking for work
    • Presently not employed outside the home, not looking for work
    • Disabled/unable to work
    • Refused/unknown
    10. What is your total household income?
    • $0 - $3,000
    • $3,001 - $16,500
    • $16,501 - $24,000
    • $24,001 - $34,500
    • $34,501 - $49,999
    • $50,000 - $74,999
    • $75,000 - $99,999
    • $100,000 - $124,999
    • $125,000 and greater
    • I prefer not to say
    11. Do you currently receive any public government benefits or benefits from “state-specific name” (e.g., Medicaid, food stamps, SSI, or welfare cash assistance)?


    • Child care subsidies
    • Child Tax Credit
    • Disability benefits
    • Earned Income Tax Credit
    • Education and training assistance
    • Housing voucher or public housing
    • Medicaid
    • Medicare
    • Military medical insurance
    • Retirement benefits
    • Social Security Insurance (SSI)
    • State Children’s Health Insurance Program (SCHIP)
    • State or local emergency assistance program
    • Supplemental Nutrition Assistance Program (SNAP)
    • Temporary Assistance to Needy Families (TANF)
    • Transportation subsidies
    • Unemployment compensation
    • Veteran’s benefits