DEMOGRAPHIC INFORMATION  (Please Check or Complete Response)


  1.  DATE OF BIRTH:        2.  SEX:  M    F

  3.  ARE YOU CURRENTLY A PARENT:   YES    NO
     AT WHAT AGE WERE YOU A PARENT

  4.  AGES OF CHILDREN:

  5.  GENDER OF CHILDREN:  M/F 

  6.  MARITAL STATUS:

  7.  EDUCATIONAL BACKGROUND:
High School Diploma or GED or Highest Grade Completed
     Bachelor's Degree
     Master's Degree
     Ph.D. Degree
     Other

  8.  ETHNIC BACKGROUND:  
    African American
    Hispanic/Latino
    Asian/Pacific Islander
    Caucasian
    Other

9.  HOUSEHOLD INCOME:
    UNDER 10,000 
    $10,000 to $40,000
    $40,000 to $70,000
    $70,000 to $100,000
    over $100,000

  10.   EMPLOYMENT STATUS:
       Full Time
       Retired
       Volunteer
       Student
   

11.  MY PARENTS ARE:
      Still married
      Divorced               Your age at divorce
      Mother deceased,   Your age at death  
      Father deceased,    Your age at death  


  12. I WAS PARENTED BY: (Check One)
      Biological parents
     Biological mother and step-father
     Biological father  and step-mother
     Single mother
     Single father
     Adopted parent(s)
     No father present
     I do not know my father
     I was raised in joint custody

13. Did your father   or mother
have an addiction to:  (Check all that apply)
Drugs
Alchohol
Gambling

14. Did your father   or mother
have a chronic illness (mental or physical)
that affected their ability to parent you?
YES   NO


  PARENTING INVENTORY - We are conducting a study on specific aspects of parenting

  Please indicate whether these general statements are True or False:

  15. Sons are more likely than daughters to identify with and feel closer to their fathers.
    TRUE        FALSE

  16. Being a father does not come naturally.  
    TRUE        FALSE

  17. Fathers tend to withdraw emotionally from their children during divorce.  
    TRUE        FALSE

  18. Mothers are more likely than fathers, to put children in the middle during a divorce.
    TRUE        FALSE

  19. Mothers communicate with their children using words and fathers using actions.
    TRUE        FALSE

  20. Fathers are often experienced as the disciplinarian in families.
    TRUE        FALSE

  21. Rough and tumble play with fathers is less personal than play with mothers.
    TRUE        FALSE

  22.  Fathers are funnier than mothers.
    TRUE        FALSE

  23. Fathers first bond with their children in:  
    Pregnancy       Within first 3 years          Grade school         Adolescence

 
  Please answer the following with your own family, close relatives or friends in mind.  Circle as many as   apply
  24.  Between ages 0-3 who did you feel closest to growing up?
      Mom       Dad          Brother/sister         Grandparent      Other Mom       Dad          Brother/sister         Grandparent      Other Mom       Dad          Brother/sister         Grandparent      Other Mom       Dad          Brother/sister         Grandparent      Other Mom       Dad          Brother/sister         Grandparent      Other Mom       Dad          Brother/sister         Grandparent      Other Mom       Dad          Brother/sister         Grandparent      Other Mom       Dad          Brother/sister         Grandparent      Other Mom       Dad          Brother/sister         Grandparent      Other
  Circle One if applicable.
  33. Losing my mother as a child made me feel like I really lost both parents.
                             1      2       3       4       5       6       7
  34. Losing my father as a child made me feel like I really lost both parents.
                             1      2       3       4       5       6       7
  Parents and children often act in ways that neither want to remember because of bad   memories and feelings experienced.  However, those times have important effects in our   lives.  
 
  For the following questions, please indicate the degree to which your parents used these techniques to   discipline you.
  35.  When my father got mad he would threatened to leave.
                             1      2       3       4       5       6       7
  36.  When my mother got mad she would threatened to leave      
                             1      2       3       4       5       6       7
  37.  When my father got mad he would ignore or refuse to talk to me.
                             1      2       3       4       5       6       7
  38.  When my mother got mad she would ignore or refuse to talk to me.
                             1      2       3       4       5       6       7
  39.  Say they would call the police or other authorities to come and take you away.
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  40.  Say they would leave you someplace if you did not behave.  
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  41.  Say they would send you away to live with relatives or friends.
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  42. By spanking me.
                             1      2       3       4       5       6       7
  43.  By yelling, shouting, or cursing at me.
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  44.  I got involved in many conflicts with my peers growing up.
                             1      2       3       4       5       6       7
  45.  I had difficulty making friends growing up.
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   Please rate the following about your own family:
  46.  My father was a traditional breadwinner and provider.  
                             1      2       3       4       5       6       7
  47.  My mother worked outside the home.
                             1      2       3       4       5       6       7
  48.  My grandparents helped take care of me.
                             1      2       3       4       5       6       7
  49.  How often did your parents argue when you were living at home.
                             1      2       3       4       5       6       7
  50.  How often did you parents threaten to separate or divorce.
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  51.   My father’s top priority for a successful life was self-discipline and self-reliance.
                             1      2       3       4       5       6       7
  52.My father’s top priority for a successful life was mutual respect, personal fulfillment and caring for myself and others.
                             1      2       3       4       5       6       7
  53.  The older I get the closer I feel to my mother.
                             1      2       3       4       5       6       7
  54.  The older I get the closer I feel to my father.
                             1      2       3       4       5       6       7
  55.  I have many things about myself that I don’t like that remind me of my father.  
                             1      2       3       4       5       6       7
  56.  I have many things about myself that I don’t like that remind me of my mother.
                             1      2       3       4       5       6       7
  57.  I am comfortable in a social environment like my mother.
                             1      2       3       4       5       6       7
  58.  I am comfortable in a social environment like my father.
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  59.  I felt understood when I talked to my father.
                             1      2       3       4       5       6       7
  60.  I felt understood when I talked to my mother.                                                    
                             1      2       3       4       5       6       7
  61.  My father was responsive and available whenever I needed him.
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  62.  My mother was responsive and available whenever I needed her.
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  63.  My father was consistent in his approach towards me.               
                             1      2       3       4       5       6       7
  64.  My mother was consistent in her approach towards me.
                             1      2       3       4       5       6       7
  65.  I felt wanted by my mother.
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  66.  I felt wanted by my father.
                             1      2       3       4       5       6       7
  67.  My relationship with my father changed a lot during the different stages of my life.
                             1      2       3       4       5       6       7
  68.  My relationship with my mother changed a lot during the different stages of my life.
                             1      2       3       4       5       6       7
  69.  I approach most things in my life with confidence.                    
                             1      2       3       4       5       6       7
  70. I am satisfied with the friendships I have as an adult.
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  71. I would like to parent my children the way my father parented me.
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  72. I would like to parent my children the way my mother parented me.  
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  73. I often had my own baby sleep with me.
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  74. I have close relationship with my daughter(s)
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  75. I have a close relationship with my son (s)
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  These questions concern your experience in romantic relationships.  Take a moment to   think about these experiences and answer the following questions with them in mind.

  76. Read each of the three self-descriptions below (A,B and C) the then place a check mark next to the single   alternative that best describes how you feel in romantic relationships or is nearest to the way you feel.  (Note: The   terms “close” and “intimate” refer to psychological or emotional closeness, not necessarily to sexual intimacy.

A.            I am somewhat uncomfortable being close to others.  I find it difficult to
                trust them completely and difficult to allow myself to depend on them.
                I am nervous when anyone gets too close, and often, want me to be
                more intimate than I feel comfortable being.

B.            I find it relatively easy to get close to others and am comfortable
                depending on them and having them depend on me.  I do not worry
                about being abandoned or about someone getting close to me.

C.            I find that others are reluctant to get as close as I would like.  I often
                worry that my partner does not really love me or will not want to stay
                with me.  I want to get very close to my partner, and this sometimes
                scares people away.

  Now please rate each of the descriptions above to indicate how well or poorly EACH description corresponds to your   general relationship experience.
  
  Style A
                          1      2       3       4       5       6       7
                   Dissagree strongly                      Neutral/Mixed                                       Agree Strongly
 
  Style B
                          1      2       3       4       5       6       7
                   Dissagree strongly                             Neutral/Mixed                                       Agree Strongly
  
   Style C
                          1      2       3       4       5       6       7
                   Dissagree strongly                      Neutral/Mixed                                        Agree Strongly
  If you have answered all the questions, click on this button to submit the form