Family Evaluation Family EvaluationThank you for taking the time to fill out this form. We want to continue to grow and improve our services. Your information will be kept in confidence, unless you request otherwise. Your input will make a difference. Thank you!Name (optional) First Last What is your race?American Indian / Alaska NativeAsianBlack or African-AmericanMultiracialNative Hawaiian or other Pacific IslanderLatino / HispanicWhiteWhat is your annual income?Up to $30,000$30,000 to $50,000$51,000 to $75,000Over $75,000What is your marital status?SingleMarriedSeparatedDivorcedOtherPlease indicate how many children you have:How did you hear about MomsBloom? (Check all that apply) Friends Family Newspaper / Ad Internet Practitioner (please specify below) Support group (please specify specify below) Other (please specify below) Please specify:Who was your volunteer?What tasks did the volunteer do? Light household chores Watched the baby Assisted with newborn care Watched and cared for siblings Helped with meals Conversed / listened to parent(s) Gave mom time to take care of herself Educated and answered questions Suggested resources, referrals, and networking opportunities Other (please indicate below) Please indicate other ways your volunteer supported you:On average, how many hours per week did your volunteer spend with you?Less than 1 hour1 hour2 hours3 hours4 hours5 hours6+ hoursWas this enough?YesNoPlease indicate how many hours would be sufficient:How many months did you have a volunteer?Less than 1 month1 to less than 2 months2 to less than 3 months3+ monthsWas this enough?YesNoPlease specify how many months would be sufficient?What other support do you have besides MomsBloom? (Check all that apply) Friends Family Significant other Support group / organization Church Other I don't have additional support Please specify other:Have you experienced symptoms of postpartum depression and/or anxiety with your current birth?YesNoIn general, my symptoms of postpartum depression and/or anxiety have improved since participating in the MomsBloom program:Strongly agreeAgreeDisagreeStrong disagreeIndicate which symptoms have improved. Check all that apply. Sadness Anxiety Depression Agitation or irritability Feelings of isolation Feelings of worthlessness or guilt Lack of pleasure or interest in most or all activities Loss of concentration Loss of energy Problems doing tasks at home or work Trouble sleeping Fear Other Please specify:Please indicate what has helped alleviate the above symptoms. Check all that apply. Prescription medication Talking with my volunteer Social interactions Sleep Exercise Extra help in taking care of the home or child(ren) Involvement in a support group (please specify) Other (please specify) Please specify:Describe any changes that have occurred in your family as a result of participating in the MomsBloom program? Please check all that apply. Less stressful family environment Ability to spend more time together as a family More organized home Improved relationship with significant other Improved relationship with child/children Other Please specify other:Please select best option from the drop down menus for each statementPlease select best option from the drop down menus for each statementAfter participating in the MomsBloom program, I am more confident in my parenting skills.Strongly agreeAgreeDisagreeStrongly disagreeI feel a greater sense of support since participating in the MomsBloom program.Strongly agreeAgreeDisagreeStrongly disagreeI felt that my volunteer's skills matched my level of need.Strongly agreeAgreeDisagreeStrongly disagreeMy volunteer was knowledgeable and helpful.Strongly agreeAgreeDisagreeStrongly disagreeI felt a great deal of comfort with my volunteer.Strongly agreeAgreeDisagreeStrongly disagreeOverall, the MomsBloom program met my needs.Strongly agreeAgreeDisagreeStrongly disagreeIn order to grow to serve families better, what would you like to see different or in addition to the MomsBloom program?Any other comments?Are you willing to share how MomsBloom supported you?YesNoIf yes, please tell us your name and the best way to reach you.I am interested in volunteering with MomsBloom in the future.YesNoMaybe This iframe contains the logic required to handle AJAX powered Gravity Forms.