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Family Needs & Affordability Survey

The following confidential survey is designed to learn about what services your family needs and can afford. Please be thoughtful and honest in your responses. The survey should take you less than 5 minutes to complete. Thank you very much! (note: questions with asterisks are required)

1. State of residence *

2. Age *

3. Gender *

Female
Male

6. Number of children (select all that apply) *

One or More Children 0 to 4 Years Old
One or More Children 5 to 11 Years Old
One or More Children 12 to 14 Years Old
One or More Children 15 to 18 Years Old
One or More Children Over 18 Years Old
I Do Not Have Children

If you do not have any children proceed to question number 16.

7. Household income (optional)

What is your total income before taxes or other deductions (gross earnings)

8. Name, e-mail address, and phone (optional)

To be included in a future anonymous survey or confidential interview include your contact name, e-mail address, and phone number.

9. What was your relationship status when your child or children were born? (optional)

Married or with life partner
Unmarried and co-habitating with biological parent
Unmarried and not co-habitating with biological parent
Varied (more than one child with more than one partner)

10. Do you receive child support? (optional)

Yes
No

11. Do you pay child support? (optional)

Yes
No

12. How many children are you the custodial parent of? (optional)

All
Some
None

Personal and Family Service Needs

For each of the following services, please select the level of need!

13. Evening Childcare (babysitting) *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

14. Before-and-after-school Childcare *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

15. Daycare For Children 5 Years Old and Under *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

16. Any-hour Drop-in Daycare *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

17. Child Tutoring *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

18. Transportation or Chauffeur *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

19. Financial Services (planning, tax return preparation, budgeting, credit counseling, etc.) *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

20. Legal Services *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

21. Diet, Exercise, Fitness & Health Counseling *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

22. Massage and Spa Treatments *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

23. Food Delivery or Preparation *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

24. Housekeeping or Home Organization *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

25. Foreign Language Instruction *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

26. Central and Neutral Child Drop-off and/or Pick-up Location for Shared Parenting *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

27. Child Discipline, Bullying, or Manners Classes *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

28. Information Technology Training For Child, Parent, and/or Grandparent *

Currently Use
Needed (and plan to buy)
Needed (but can't afford)
Not Needed

29. Other Desired Services (optional)

Write in other desired services not listed above

30. What one thing would you describe is the most challenging aspect of single parenting? (optional)