Wig Pre-Participant Survey
In order for the Maggie's Wigs 4 Michigan program to provide excellent service, we need you honest feedback. Your response help us to do this.
Name (optional)
First Name
Last Name
Date:
/
Month
/
Day
Year
Date
One a scale from 1 to 4 with 1 being strongly disagree and 4 being strongly agree, please rate the following. Before receiving your wig...
Strongly Disagree
(1)
Disagree (2)
Agree
(3)
Strongly Agree
(4)
I enjoy going out in public
I feel comfortable around my friends
I participate in social activites
I feel confident about my appearance
How can Wigs 4 Kids continue to support you?
Please check the following:
Educational
Music Therapy
Tutoring
Art Therapy
Medical
Physical Fitness
Nutrition Classes
Individual & Family Talk Therapy
Social
Field Trips
Peer Mentoring
Cooking Classes
What is your goal by participating in the program?
To feel more confident
To like the way I look
To feel like myself again
To make new friends
Other
Are you a boy or a girl?
Please Select
Boy
Girl
How old are you?
3-5
6-9
10-12
13-18
Preview PDF
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform