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Rephobia Survey
Please fill out our survey for a chance to win a £30 OneForAll Voucher
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Email
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2
Age
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3
Gender
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Please Select
Male
Female
Non-Binary
Prefer not to say
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Male
Female
Non-Binary
Prefer not to say
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4
In which city are you located?
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(eg. Belfast, London, Strabane, etc.)
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5
Do you have any phobias?
*
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(An extreme or irrational fear of or aversion to something; Fear of Heights, Flying, Driving, Needles etc.)
Yes
No
Unsure
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6
Do you experience any of the following:
*
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Fear of Flying
Fear of Driving
Fear of Heights
Fear of Spiders
Fear of Needles
Fear of Public Speaking
Claustrophobia
Fear of Water
Other Kind of Fear
Other
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7
Describe which other fear/s you have
*
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Please name as many as necessary
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8
Type a question
Spiders
Heights
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9
Which of your fears (can be any) have affected you for the longest?
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10
How many years has this fear affected you for?
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11
What treatment have you received for one or more of your Phobia?
You can select multiple, or one option:
None
Cognative Behavioral Therapy (CBT)
Exposure Therapy
Virtual Reality Exposure Therapy
Medication
Other
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12
For what 'Other' treatment have you chosen?
*
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Please describe any other treatments
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13
Why have you chosen to not seek treatment?
*
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Too expensive
No time
Not worth the hassle
Don't consider my fears to be severe enough
Don't know who to ask or where to start
Other
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14
For what 'Other' reason have you chosen?
*
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Please describe any other reasons
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15
Did you find the treatment to be effective?
*
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Yes
No
Unsure
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16
Rank the effectiveness of your Treatment
Please rank 1-5
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17
Provide a brief description of the Treatment
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18
Grade the severity of your Phobia *before* Treatment
*
This field is required.
(5 being an extremely severe phobia and 1 being not at all)
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19
Grade the severity of your Phobia *after* Treatment
*
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(5 being an extremely severe phobia and 1 being not at all)
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20
Have you ever used Virtual Reality?
*
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YES
NO
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21
How often do you use Virtual Reality?
Please select the option which is most accurate:
Once a day
Once a week
Once a month
Once a year
Less often than a year
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22
How many times have you used Virtual Reality headset over the last week?
Please select the option which is most accurate:
1-2 times
3-4 times
5-6 times
More than 6 times
Never
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23
How comfortable are you using Virtual Reality?
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24
Select any options you believe to be true about using Virtual Reality?
VR can be a powerful tool for education and training
VR can cause motion sickness or disorientation
VR is still a relatively new technology with ongoing advancements
VR has the potential to revolutionize mental health treatment, including exposure therapy
VR can offer immersive and engaging entertainment experience
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25
Select any options you believe to be true about using Virtual Reality?
I believe VR can create a sense of unparalleled immersion
I believe VR is expensive and costly
I believe VR is technology is not designed to be used by the older population
I believe VR has the potential to create new forms of healthcare
I wonder how long it takes to get the hang of VR. Seems like it could be complicated.
I believe people will benefit from Virtual Reality
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26
Thank You! We will contact you shortly.
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27
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