Questionnaire for the Nurturing Family

The following questions are intended to provide us with an accurate representation of your family.
This information will help ensure a compatible placement of a Client within your Nurturing Family.

As you answer the questions below, it is only natural that you may have questions about our organization
or the nurturing experience itself. We encourage you to talk with Network staff members to gain a better
understanding of the role of the Nurturing Family. Should you be interested in learning more,
we also have videotapes and related training materials.

After submitting this questionnaire, you can follow the link back to the Nurturing Family
page. There, you may follow the link to the Husband or Wife Questionnaires.

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	Date	/ /
A. Basic Information
	Wife's full name        Birthdate
	Husband's full name        Birthdate
	Address
	City/State Zip
	Home phone:    ()        Fax ()
	Business phone(s):   Wife:  ()        Fax ()                          Husband:  ()        Fax ()
	Email address
	Location of Home      Rural      Suburb      Urban
	If rural, what is your closest large city?
	Population of City/Town:
B. Employment
	Wife's Occupation:
	Employer:
	Hours worked daily:       Average overtime per month:
	Do you consider your job to be a high stress position?		Yes No
	Does it take you out of town on travel?		Yes No
	If so, approximate number of days per month:
	Husband's Occupation:
	Employer:
	Hours worked daily:       Average overtime per month:
	Do you consider your job to be a high stress position?		Yes No
	Does it take you out of town on travel?		Yes No
	If so, approximate number of days per month:
C. Financial Information
	Normally, The Nurturing Network does not provide financial support to our Nurturing Families who share their homes with our Clients. It is our belief that if you become a Nurturing Family, you will experience the rewards for your kindness and generosity. However, it is also important that you not suffer any financial hardship as a result of sharing your home. Therefore;
	Do your family's finances comfortably allow you to accept a mother-to-be in residence without reimbursement for room and board? Yes No
	If not, please explain:
	Do you have reason to expect any substantial adverse changes in your family's financial situation during the next year? Yes No
	If not, please briefly explain: