Questionnaire on Parental Influence

NOTE: Please read first : Introduction to Questionnaire on Parental Influence

Please fill out the survey form below. Then click submit.

DEMOGRAPHICS

Age

How many Children do you have?

How many siblings do/did you have?

Biological Birth Sex

Male
Female

Current Sexual Orientation

Cultural Ethnic Background

Educational Level Achieved

ADULTS RESPONSIBLE FOR RASING YOU. Please indicate first the parental figure(s) involved in raising you. Then indicate for how long.

If raised by Biological Mother , please indicate from what age it started and up to what age when mother/child relationship ended.

If raised by Biological Father , please indicate from what age it started and up to what age when father/child relationship ended.

If raised by a single parent, Father or Mother, please indicate from what age it started and up to what age when single parent/child relationship ended.

OTHER RESPONSIBLE ADULTS WHO RAISED YOU

If raised by a Stepmother , please indicate from what age it started and up to what age when stepmother/child relationship ended.

If raised by a Stepfather , please indicate from what age it started and up to what age when stepfather/child relationship ended.

Other parental type adults (relatives or?) responsible for raising you? Starting at what age: ____ to what age: ____

Changes in “parental” individual(s) prior to your leaving that environment and at what age to what age:(divorce, death, etc.)

Comments (issues not covered)

ATTITUDES TOWARDS PARENTAL ROLES. Rate from 1-10, 10 being the most positive. Please use the number slider below.

Did you feel good or not about them in their roles as: FEMALE? Role (mother, aunt, stepmother, etc.)

Selected Value: 0

Did you feel good or not about them in their roles as: MALE? Role (father, uncle, stepfather, etc.)

Selected Value: 0

Did you feel good or not about them in their roles as: WIFE?

Selected Value: 0

Did you feel good or not about them in their roles as: HUSBAND?

Selected Value: 0

Did you feel good or not about them in their roles as: MOTHER?

Selected Value: 0

Did you feel good or not about them in their roles as: FATHER?

Selected Value: 0

ACCEPTED ROLES – OR NOT: Rate yourself from1-10 in terms of how alike them you are in those roles. (10 being most like your same sex parent, 1 being least like . Please use the number slider below.

Sex/Gender role (male or female)

Selected Value: 0

Marital Role (wife or husband)

Selected Value: 0

Parental Role (mother or father)

Selected Value: 0

If you see yourself as taking an opposite position on these roles, please rate how opposite. (10 being the most opposite to 1 being the least opposite). Please use the number slider below.

Sex/Gender role (male or female)

Selected Value: 0

Marital Role (wife/husband)

Selected Value: 0

Parental Role (mother/father)

Selected Value: 0

CURRENT RELATIONSHIP: If you are in a long standing, married or co-habitating, relationship please respond as to whether they are like/unlike your opposite sex parental role model. For example, if you are a male, is your female partner like your mother? (10 being most like your opposite sex parent, 1 being least like . Please use the number slider below.

Behavior as Male or Female

Selected Value: 0

Behavior as a Wife or Husband (only if married)

Selected Value: 0

Behavior as a parent – Mother or Father:

Selected Value: 0

Questions or comments:

Thank You for your aprticipation!