Pre-program Survey Sample - Make the Connection

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This field is for validation purposes and should be left unchanged.

What of the following roles describe how you will be using the Make the Connection program? (Select all that apply)

Parent / primary caregiver (including foster parents, step parents, and adoptive parents) of a 0-3 year old

Extended family member (e.g. grandparent, pibling [aunt / uncle], etc.) of a 0-3 year old

Other

Before starting the MTC program, reflect on your…

	Not at all true	Slightly true	Sometimes	Somewhat true	Moderately true	Very true
Knowledge. I have a strong understanding of the parent-infant attachment relationship.
Parenting Attitude / Fulfillment. I feel positive, fulfilled, and connected in my interactions with my baby.

Before starting the MTC program, reflect on your…

	Not at all true	Slightly true	Somewhat true	Moderately true	Very true
Parenting Confidence. My baby can trust that I will be there for them when they are upset.
Parenting Empathy. I make sure that my baby’s feelings are being acknowledged.
Parenting Satisfaction. I feel engaged and satisfied in my parenting role.
Self-Efficacy. I feel successful in my role as a parent.

Below is a list of ways you might have felt or behaved. Please indicate how often you have felt this way DURING THE LAST WEEK.

	Rarely or none of the time (less than 1 day)	Some or a little of the time (1-2 days)	Occasionally or a moderate amount of the time (3-4 days	Most or all of the time (5-7 days)
I was bothered by things that don’t usually bother me.
I had trouble keeping my mind on what I was doing.
I felt depressed.
I felt everything I did was an effort.
I felt hopeful about the future.
I felt fearful.
My sleep was restless.
I was happy.
I felt lonely.
I could not get motivated.
I felt terrific.

What do you hope to gain from taking the Make the Connection program?

Parent – Pre-Program Questionnaire