Client Survey 2005

Time and Talent Survey

Adoption Resource Center of Connecticut

78 Eastern Boulevard

Glastonbury, CT 06033

1.	ARC-CT conducts monthly support groups for Waiting Parents and for Post-Adoptive Parents. Were you aware of these groups?
other
		Waiting Parents?	Yes No
		Post-Adoptive Parents?	Yes No

2.	Do you have an interest in attending ARC-CT's support group for Waiting Parents? Yes No
other	2a.	If 'No', why not? (check all that apply)
		I am not currently a Waiting Parent I don't have the time I don't need this type of group/service I would have trouble accessing babysitting It is too far to travel Other:

3.	Do you have an interest in attending ARC-CT's support group for Post-Adoptive Parents? Yes No
other	3a.	If 'No', why not? (check all that apply)

			I am not currently a Adoptive Parent
			I don't have the time
			I don't need this type of group/service
			I would have trouble accessing babysitting
			It is too far to travel
		Other:

4.	The best format for a group would be: (check all that apply)
other
		A loosely structured peer support group
		An educational group with a topic and/or speaker to address adoption-related issues and general childrearing issues
		A combination support/educational group
	Other:

5.	It would be helpful to have separate groups for domestic and international adoptive parents. Yes No

6.	The best frequency for a group would be:

		Monthly
		Quarterly
	Other:

7.	The best time for a group would be: (check all that apply)
		Monday evening
		Tuesday evening
		Wednesday evening
		Thursday evening
		Saturday morning
other	Other

8.	ARC-CT currently holds two social events each year, a summer picnic and a December holiday party. How often would you attend regularly scheduled ARC-CT social events?
		Monthly
		Quarterly
		Semi-annually
other	Other

9.99	I would be interested in participating in play dates with other ARC-CT families. Yes No

10.	I would like to see ARC-CT offer the following additional social/cultural activities:
other	other:
		ARC-CT currently offers the right amount of social activities!

11.0	I would utilize a mentoring program whereby adoptive parents are matched with waiting parents to provide support, information and assistance. Yes No

12.	I would like to see ARC-CT offer the following services:
other	other:
		ARC-CT currently offers an appropriate selection of services.

13.	I would be willing to volunteer my time/talents to the following ARC-CT activities/events: (check all that apply)
		Holiday party
		Summer picnic
		Other social activities
		Fundraising activities
		Awareness raising activities
		Grant writing
		Public relations/advertising
		Administrative support
		Mentor waiting parents and/or new adoptive parents
		Oversee the resource library
		Speak to school, church and civic groups about adoption
		Advocate with elected officials on behalf of adoption issues
		Edit an online ARC-CT newsletter
other	Other:

14.	I have the following talents/skills that I would be willing to share with ARC-CT: (check all that apply)
		Writing
		Finance/budgeting
		Grant writing
		Group facilitation
		Clinical skills/counseling
		Computer/technical
		Medical (esp. pediatric)
		Graphic design
		Publicity/public relations
		Event planning
		Public speaking
		Artwork/crafts
		Knowledge or experience with special needs children
		Legal
		Complementary therapies (i.e. Reiki, massage, yoga)
other	Other:

15.	I go to the following sources when I need support or information about adoption-related issues:
other	Other:

16.	I would like to see the ARC-CT Parents' Group become involved with the following activities/issues:
other	Other:

Remember, while the fields below in the Personal section are optional, if you indicated an interest in becoming involved, please enter at least your name, phone number and an email address, if you have one so we may contact you.

All data collected in this survey is treated as confidential and will NOT be shared with any external third party.

Personal
	Primary First Name:
	Primary Last Name:
	Alternate First Name:
	Alternate Last Name:
	Address:
	City:
	State:
	Zip Code:
	Home Phone:	Best time to call: AM PM
	Email1:
	Email2:
	Adoption Status: Waiting Completed
	Adoption Type: International Domestic


Child One:
	Age:
	Adopted: Yes No
	Country: Other:
		If China, what province? Other:

Child Two:
	Age:
	Adopted: Yes No
	Country: Other:
		If China, what province? Other:

Child Three:
	Age:
	Adopted: Yes No
	Country: Other:
		If China, what province? Other:

Child Four:
	Age:
	Adopted: Yes No
	Country: Other:
		If China, what province? Other:

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