Lifeline Cleveland Potential Participant Questionnaire

Lifeline Cleveland Participant
Thank you for your interest in Lifeline Cleveland. This space is created with love, safety, and support in mind for women who are navigating heavy moments.

Please take a few moments to fill out this short form. Your responses help us understand your needs and make sure this program is the right fit for you.

COMPLETING THIS FORM DOES NOT GUARANTEE YOUR ACCEPTANCE INTO THIS PROGRAM

🧠 If you are in immediate danger or need urgent support, please call or text 988 – the Suicide & Crisis Lifeline – available 24/7.
Name*

First NameLast Name
Age:*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you female (Assigned female at birth)? This program is designed for women and girls. If you are not female, PLEASE DO NOT COMPLETE THIS FORM*

Yes, I am female (female assigned at birth)
Screening & Needs Assessment
Have you ever experienced suicidal thoughts or behaviors?*

Yes, currentlyYes, in the pastNo
Are you currently working with a therapist, counselor, or mental health professional?*

YesNo
If yes: "Please share anything you're comfortable with."
What challenges are you currently facing that you’d like support with? (Checkboxes – choose all that apply)*

Depression or anxietyGrief or lossRelationship/family stressSelf-esteem or identity issuesTrauma or abuseLoneliness/isolationOther
Other: Please complete
Why are you interested in joining this program?*
What would a healing experience look like for you?*
What would help you feel seen, safe, and supported?*
Do you feel safe participating in a small group therapy session?*

YesNo
If no: “Would you prefer a different kind of support?”
Do you have any allergies, sensitivities, or physical limitations we should be aware of?*

YesNo
If yes, please explain
Would you be open to receiving a Healing Box designed just for you?*

YesNo
🔒 Confidentiality Agreement

Your responses are strictly confidential and will only be viewed by members of the Lifeline Cleveland committee. Your privacy is important to us.

No information will be shared outside of this program without your written consent, unless there is an immediate concern for your safety that requires us to involve appropriate support services.
I understand and agree to the confidentiality policy.
Thank you so much for your openness. We review every submission with care and will be in touch with next steps. Please know that your story matters, and your healing matters.

💌 If you have any questions or need support before then, please email us at Naomicle216@gmail.com
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Lifeline Cleveland Participant

Screening & Needs Assessment