Questionnaire for Broken Family

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1. With whom you are living with?
Father Mother Guardian
Others: ________________
2. Since when you experienced having a broken family?
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] None
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