Living Successfully Post Course Survey
Contact Information
First Name
Last Name
City
State/Province
- State -
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
AS
FM
GU
MH
MP
PR
PW
VI
AA
AE
AP
Email
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Additional Information
Today's date
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I identify as
(Optional)
Black/African American
Hispanic
Asian/Pacific Islander
Native American
Caucasian (non-Hispanic)
Other
Other
(Optional)
My home community is
(Optional)
Urban
Suburban
Rural
Other
Other
(Optional)
My age range is
(Optional)
Under 18
19-30
31-40
41-65
65-75
Over 75
I am most interested in
(Optional)
I am most interested in is required.
Bipolar Disorder Information
Depression Information
Information about Helping a Love One
Other
Other
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My understanding level on the topic of DEPRESSION is currently
(Optional)
Very High
High
Average
Low
Unsure
My understanding level on the topic of BIPOLAR DISORDER is currently
(Optional)
Very High
High
Average
Low
Unsure
My understanding level on the topic of TREATMENT FOR MOOD DISORDERS is currently
(Optional)
Very High
High
Average
Low
Unsure
My understanding level with the topic of PEER SUPPORT FOR MENTAL HEALTH CHALLENGES is currently
(Optional)
Very High
High
Average
Low
Unsure
Overall, I had a positive experience during the "Living Successfully" Course
(Optional)
Strongly Agree
Agree
Somewhat Agree
Disagree
The "Living Successfully" Course Facilitator did his/her job well
(Optional)
Strongly Agree
Agree
Somewhat Agree
Disagree
The materials and handouts were helpful
(Optional)
Strongly Agree
Agree
Somewhat Agree
Disagree
I would recommend the "Living Successfully" Course to other people like me.
(Optional)
Strongly Agree
Agree
Somewhat Agree
Disagree
The most important thing that I learned during the "Living Successfully" course is:
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Any other comments?
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