* First Name:
* Last Name:
* Email Address:
 
Basic Questions
This information is collected for demographic research purposes only. It is not factored into the final results of your quiz.
 
In which age range do you belong?
 
Which applies to you?
 
How many children do you have?
 
How old are your children?
 
Do you have any relatives, not your children, that you are a caretaker for (eg. parents, grandparents, other)?
 
Are you employed?
 
How satisfied are you with your career and/or job?
 
Which statement do you most agree with in regards to your financial situation?
 
Emotional Exhaustion
 
1. How often do you feel exhausted regardless of how much rest and sleep you get?
 
2. How often do you experience guilt? (eg. for your actions, not being enough, or not doing enough)
 
3. Do you dread getting out of bed to start the day?
 
4. How often do you feel bored?
 
5. Do you have difficulty with concentration and attention and find it a challenge to get things done?
 
Emotional Stress/Detachment Questions
 
1.Do you isolate yourself in relationships, whether with friends, family, or acquaintances?
 
2.Do you participate in interests/hobbies/activities that you enjoy and look forward to doing?
 
3.How often do you feel irritated, annoyed, or stressed?
 
4. Which statement most accurately summarizes your view of the future?
 
5. How often do you snap, use sarcasm, or react annoyed to your children and family?
 
6. When your child is upset, hurt, or frustrated, how do you respond?
 
7. How often do you feel joy, gratitude, and happiness?
 
8. Do you find yourself avoiding your child by placing them in front of the television or using screen time, such as gaming or videos, instead of interacting with them because you don't have the energy?
 
Personal Accomplishments
 
1.Which statement best describes your to-do list for any given day?
 
2. Do you have difficulty taking care of your children and find their needs overwhelming?
 
3. Do you put pressure on yourself to do most things "perfectly"?
 
4. How often do you feel a sense of accomplishment at the end of the day?
 
5. How often do you hear positive feedback (eg. "Nice job," "you're a wonderful mom," "thank you," "I appreciate you")?
 
6.How satified are you with your career and/or job?
 
Self-Care Behaviors
 
1.How often are you able to get at least 7 hours of sleep?
 
2. Which coping mechanisms, or activities/ways to manage stress, do you use?
 
If other personal interests, please describe:
 
If other hobbies, please describe:
 
3. Which statement best describes how you feel about yourself as a dad?
 
4. How often do you make time for yourself to reset, replenish, and reset?
 
Social Support
 
1.How often do you experience tension with one or more family members?
 
2. Which statement most closely describes your friendships?
 
3. Would you describe your immediate family as supportive? This includes emotional and tangible support.
 
4. What is the most stressful part of parenting for you?
 
Open-Ended Questions
This information is collected for research purposes only. It is not factored into the final results of your quiz.
 
What is the main barrier to taking care of yourself?
 
Is there a topic or concern that you'd like more information on? If so, what would you like to know?
 
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