Family Communication Survey

Transcription

1 Please do not write in this box: ID: Family: Family Communication Survey The purpose of this survey is to determine the characteristics of communication between parents and their adolescent children. Please answer all of the following questions in reference to the family with whom you currently live.. Please identify yourself by filling in the appropriate circle: Mother Father Stepmother Stepfather. What is your current marital status: Married/ Remarried Divorced/ Separated Single/ Married Widowed. How many years have you been a member of this family:. Your Age: Instructions: Please fill in the number to the right of each question for the answer which best describes your communication with your child (or stepchild). Base your responses on the scale to the right ( ).. How often do you talk with your child about your friendships? Very. How often do you discuss with your child your personal mistakes?. How often do you interrupt your child when he or she is talking?. How often do you plan family activities together with your child?. How often do you retreat to a private space in your home (not including sleeping)?. How often do you listen to your child when he or she is talking to you?. How often do you discuss with your child questions about his or her sexuality? 8. How often do you discuss with your child past arguments in your relationship with him or her? 9. How often do you have to repeat yourself when talking to your child?. How often do you close your bedroom door?

2 Very. How often do you answer your child when he or she calls you?. How often does your child interrupt you when you are talking?. How often do you discuss with your child your bad behavior, such as being disrespectful?. How often do you talk with your child about your daily activities?. How often do you ignore your child when he or she is talking to you?. How often do you discuss your feelings toward your child with him or her?. How often do you keep secrets from your child? 8. How often does your child listen to you when you are talking? 9. How often do you include your child in your activities?. How often do you discuss family rules with your child?. How often does your child have to repeat him or herself when talking to you?. How often do you discuss with your child intimate, non-sexual details of your relationship with his or her other parent?. How often do you write in a private diary?. How often do you experience your child ignoring you when you are talking?. How often do you express agreement with your child when he or she makes a statement?. How often do you share with your child information about events in your life? Please place the completed survey in the envelope provided and return. Thank you for your participation. Copyright 999, H. Paul LeBlanc III. All rights reserved.

3 Please do not write in this box: ID: Family: Family Communication Survey The purpose of this survey is to determine the characteristics of communication between parents and their adolescent children. Please answer all of the following questions in reference to the family with whom you currently live.. Please identify yourself by filling in the appropriate circle: Daughter Son Stepdaughter Stepson. In what order were you born: {If adopted, fill in the number indicating your age relative to adopted siblings.} First child/ Only child Second child Third child. With how many brothers and sisters do you currently live:. Your Age: Fourth child Instructions: Please fill in the number to the right of each question for the answer which best describes your communication with your mother (or stepmother). Base your responses on the scale to the right ( ).. How often do you talk with your mother about your friendships? Very. How often do you discuss with your mother your personal mistakes?. How often do you interrupt your mother when she is talking?. How often do you plan family activities together with your mother?. How often do you retreat to a private space in your home (not including sleeping)?. How often do you listen to your mother when she is talking to you?. How often do you discuss with your mother questions about your sexuality? 8. How often do you discuss with your mother past arguments in your relationship with her? 9. How often do you have to repeat yourself when talking to your mother?. How often do you close your bedroom door?

4 Very. How often do you answer your mother when she calls you?. How often does your mother interrupt you when you are talking?. How often do you discuss with your mother your bad behavior, such as being disrespectful?. How often do you talk with your mother about your daily activities?. How often do you ignore your mother when she is talking to you?. How often do you discuss your feelings toward your mother with her?. How often do you keep secrets from your mother? 8. How often does your mother listen to you when you are talking? 9. How often do you include your mother in your activities?. How often do you discuss family rules with your mother?. How often does your mother have to repeat herself when talking to you?. How often do you discuss with your mother details of your relationship with your father (or stepfather)?. How often do you write in a private diary?. How often do you experience your mother ignoring you when you are talking?. How often do you express agreement with your mother when she makes a statement?. How often do you share with your mother information about events in your life? Please place the completed survey in the envelope provided and return. Thank you for your participation. Copyright 999, H. Paul LeBlanc III. All rights reserved.

5 Please do not write in this box: ID: Family: Family Communication Survey The purpose of this survey is to determine the characteristics of communication between parents and their adolescent children. Please answer all of the following questions in reference to the family with whom you currently live.. Please identify yourself by filling in the appropriate circle: Daughter Son Stepdaughter Stepson. In what order were you born: {If adopted, fill in the number indicating your age relative to adopted siblings.} First child/ Only child Second child Third child. With how many brothers and sisters do you currently live:. Your Age: Fourth child Instructions: Please fill in the number to the right of each question for the answer which best describes your communication with your father (or stepfather). Base your responses on the scale to the right ( ).. How often do you talk with your father about your friendships? Very. How often do you discuss with your father your personal mistakes?. How often do you interrupt your father when he is talking?. How often do you plan family activities together with your father?. How often do you retreat to a private space in your home (not including sleeping)?. How often do you listen to your father when he is talking to you?. How often do you discuss with your father questions about your sexuality? 8. How often do you discuss with your father past arguments in your relationship with him? 9. How often do you have to repeat yourself when talking to your father?. How often do you close your bedroom door?

6 Very. How often do you answer your father when he calls you?. How often does your father interrupt you when you are talking?. How often do you discuss your bad behavior, such as disrespect, with your father?. How often do you talk about your daily activities with your father?. How often do you ignore your father when he is talking to you?. How often do you discuss your feelings toward your father with him?. How often do you keep secrets from your father? 8. How often does your father listen to you when you are talking? 9. How often do you include your father in your activities?. How often do you discuss family rules with your father?. How often does your father have to repeat himself when talking to you?. How often do you discuss with your father details of your relationship with your mother (or stepmother)?. How often do you write in a private diary?. How often do you experience your father ignoring you when you are talking?. How often do you express agreement with your father when she makes a statement?. How often do you share with your father information about events in your life? Please place the completed survey in the envelope provided and return. Thank you for your participation. Copyright 999, H. Paul LeBlanc III. All rights reserved.