Estrangement: Parents from Adult Children
Answers marked with a * are required.
 
1. Please indicate your gender: *

      

 
 
 
2. Highest level of schooling you have attained: *





      

 
 
 
3. Please indicate your age *
 
 
 
4. Please enter your email address.
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5. Do you belong to an organized religious group? *

      

 
 
 
6. When you were growing up, compared to other families on your country, did your parents have: (Check one) *




      

 
 
 
7. When you were raising your children, compared to other families in your country, did you have: (Check one)
*




      

 
 
 
8. When your children were growing up, did you provide any of the following:
(check all that apply)
*













      
 
 
 
9. What is your current household annual income? (Check one) *













      

 
 
 
10. Please indicate your current marital status: (Check one) *






      

 
 
 
11. In the interest of racial diversity, please indicate your identification: *





      

 
 
 
12. Occupation: Please List your occupation in the space provided. *
 
 
 
13. State/Country Please list your state if you live in the US. List your country if you live outside of the US. (e.g., Connecticut if you live in the US) or (e.g., Spain, if you live outside of the US in the country of Spain): *
 
 
 
14. Please note who you are estranged from and their CURRENT age:
Son
Son
Son
Son
Daughter
Daughter
Daughter
Daughter
 
 
 
15. Are you: *

      

 
 
 
16. How old was your son(s) or daughter(s) when the estrangement started?
Son
Son
Son
Son
Daughter
Daughter
Daughter
Daughter
 
 
 
17. How many years has estrangement/cut off been going on? (include total time even if there have been brief periods of reconciliation) *
 
 
 
18. Is your adult child in a committed relationship? *




      

 
 
 
19. Prior to the estrangement, what was your relationship like with your child?
(Check all that apply)
*









      
 
 
 
20. While growing up, did you feel that your child was dishonest.. lying, cheating, stealing, etc? *

      

 
 
 
21. Did you consistently tell your children that they were special? *

      

 
 
 
22. Did your child ever experience any of the following?
(Check all that apply)
*












      
 
 
 
23. Have you or your spouse ever:
(check all that apply)
*









      
 
 
 
24. While growing up, did your child have any learning disablitiles? *

      

 
 
 
25. If yes, please use this space to briefly describe.
 
 
 
26. Has your adult child ever concretely shared their reasons for their estrangement from you? *

      

 
 
 
27. If yes, please check all communications on this topic:



      
 
 
 
28. From your point of view, please briefly describe what you believe to be the reason for the estrangement?
*
 
 
 
29. Do you feel that you have some responsibility for this estrangement?
*


      

 
 
 
30. Have you or anyone closely involved been to therapy as a result of this issue? *

      

 
 
 
31. What other resources have you sought for help?
(check all that apply)
*




      
 
 
 
32. Has your estrangement affected your well being? *

      

 
 
 
33. If yes, please check all that apply:





      
 
 
 
34. Has your estrangement affected personal relationships? *

      

 
 
 
35. If yes, please check all that apply:



      
 
 
 
36. If you have grandchildren, are you able to see them: *


      

 
 
 
37. If yes, are your grandchildren allowed to sleep over or go somewhere with you that does not include their parents?

      

 
 
 
 
 

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