B. Study Questionnaire

Appendix B

Study Questionnaire

Thank you for agreeing to participate in this study! Please complete the questionnaire below and return it via email, or snail mail, based on your preference. If you have any questions while filling this out, please email me at 21stcenturymom.tb@gmail.com. This questionnaire must be completed and returned before your first interview can be scheduled.

Please note that the information in this questionnaire is confidential and will only be used under the auspices of this research study.

This questionnaire consists of 15 questions in two sections. In the 15 questions,

please circle the answer that best represents your response, or fill in the blank.

Section I:

1. Since you became a therapist, have you experienced a personal trauma?

Yes - continue No - the subject is excluded from the study

2. Did you have childhood experiences of trauma?

Yes - the subject is excluded from the study No - continue

3. If you answered Yes to question 1, would you be willing to discuss this trauma as part of this research project or with this researcher?

Yes - continue No - the subject is excluded from the study

4. Are you a Christian? Yes - continue No - the subject is excluded from the study

5. What is your certification and/or license? (if none, put none):

6. Are you a Christian psychotherapist or psychologist for whom Christian faith beliefs are foundational to your clinical practice?

Yes - continue No - the subject is excluded from the study

7. This study will include the collection of verbal data from you through a series of interviews. Do you agree to allow me to audio record your responses?

Yes - continue No - the subject is excluded from the study

8. How many years have you been a Christian psychotherapist of psychologist? __________number of years.

9. Please indicate the pseudonym you would like to be addressed by during data collection: ___________________________.

10. Please indicate the theoretical orientation you most identify with: ___ Attachment theory ___ Classical Drive theory ___ Ego psychology ___ Object relations theory ___ Relational psychology ___ Self-psychology ___ Other: _____________________

Section II:

11. What is your gender? ___________________

12. What year were you born? ___________

13. What is your race? ___________

14. What is your ethnicity? _______________

15. What is the highest level of formal education you have completed? ___ No schooling completed ___ Nursery school to 8th grade ___ Some high school, no diploma ___ High school graduate, diploma or the equivalent (for example: GED) ___ Some college credit, no degree ___ Trade/technical/vocational training ___ Associate degree ___ Bachelor’s degree ___ Master’s degree ___ Professional degree ___ Doctorate degree ___ Other: _________________________________

Thank you for completing this questionnaire! Your time and participation are very much appreciated.

Teresa Barnes 8686 Quinn Pt. Colorado Springs, CO 80924

719-425-9366

21stcenturymom.tb@gmail.com