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Questionnaire for Broken Family

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Questionnaire for Broken Family
EFFECTS OF HAVING A BROKEN FAMILY”
1. With whom you are living with?
Father Mother Guardian Others: ________________
2. Since when you experienced having a broken family? ____y/o
3. How many siblings do you have? [pic] Only Child [pic] 2 [pic] 3 and above
4. How many friends do you have?
[pic] 1-3 friends [pic] 4-7 friends [pic] 8 and above
5. What was your first reaction when you knew that your mom and dad will never be together?
[pic] happy [pic] unhappy [pic] others: (pls. specify) __________________________
6. Fill in the blank. My life will not be completed w/out my_________.
[pic] Mom [pic] Dad [pic] Others . . . why? ____________________________________________________________

__
7. Was there any instances that you decided to live on your own?
[pic] Yes [pic] No
8. Is there any circumstances that you personally approach your parents and ask what happened to their relationship?
[pic] Yes [pic] No
9. What are you idea/s why their relationship does not work?
[pic] Financial problem [pic] 3rd party [pic] Problem with relatives
Others (pls. specify) ___________________________________
10. In your own opinion, whom do you consider the reason why a broken family arises? Is it because of a nagger wife or a polygamous husband?
____________________________________________________________

_______
11. With your existence in this earth, will you consider yourself a good husband/wife in the future?
[pic] Yes [pic] No
12. Do you have any communication with your Mom/ Dad?
[pic] Mom [pic] Dad
[pic] None (if none proceed to number 14)
13. If yes, do they support you?
[pic] In financial aspects
[pic] In emotional aspects
[pic]
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