Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Block 1: Demographics:
Gender: Male Female Age: ______________ Ethnicity: Caucasian African American Latino/Hispanic Native American/Pacific Islander Asian Other:________________ Number of family members living in home:__________________________ Marital status: Married Single/never married Divorced Separated
Relationship to child diagnosed with autism (on the autistic spectrum): Parent Step Parent Legal guardian Grandparent
4. Where does your child receive treatment? (select all that apply)
In home
At school
Private practice
Outpatient facility
5. How long has your child been in treatment? 6. Do any other members of your family receive mental health services or support? 6B. Please briefly describe other family members services or support received.
Block 3: Family Satisfaction: If answered YES family member will see question #b, if answered NO family will skip #b and move onto next question #.
1. Does your childs behavior affect your family functioning? 1b. How does your childs behavior affect your family functioning?
2. Has your relationship with your child changed? 2b. How has your relationship with your child changed?
3.Would you like your relationship with your child to change? 3b. How would you like your relationship with your child to change?
4. Has your relationship with your partner changed (N/A answer choice) 4b. How has your relationship with your partner changed?
5. Would you like your relationship with your partner to change. (N/A answer choice) 5b. How would you like your relationship with your partner to change?
6. Have you noticed a change in your self-confidence/selfimage? 6b. What changes have you noticed in your self-confidence/self image?
7. Have you notice a change in how your Family copes with new routines 7b. What change(s) have you noticed in how your family copes with new routines?
8. Have you noticed a change in how your family copes with change? 8b. what change have you noticed in how your family copes with change?
9. Have you noticed a change in your familys social life? 9b. How has your familys social life changed?
10. Have you noticed a change in interactions between family members? 10b. Briefly describe how interactions between family members has changed.
11. Briefly describe something your family can do now that you did not feel was possible before.