Wellness and Community Engagement Check-In
Please share your current feelings and support needs to help us serve you better.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
On a scale of 1 to 10, how would you rate your current mental and emotional well-being?
*
1
2
3
4
5
6
7
8
9
10
How do your faith or mindfulness practices help guide you through your vitiligo journey?
Please share any support needs or concerns related to your mental/emotional health.
How are you feeling today?
Great
Okay
Neutral
Struggling
Really need support
What type of support would help you most right now?
Emotional support
Encouragement Resources
Information Events
Activities to connect with others
One on one check-in
Other
Are you currently using any treatments for your vitiligo?
Yes
No
Prefer not to say
If yes, are you experiencing any side effects from treatment?
No side effects
Mild side effectss
Strong side effects
Prefer not to say
How comfortable do you currently feel with your vitiligo?
I fully embrace it
I am learning to accept it
Neutral
Struggling with it
Prefer not to say
Do you feel society is becoming more understanding about vitiligo?
Yes — much more understanding
Somewhat more understanding
No change
Less understanding
Not sure
How connected do you feel in the community right now?
Very connected
Somewhat connected
Neutral
A little disconnected
Not connected at all
Submit Feedback
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