Language
English (US)
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Single Session Participant Survey
Please answer the questions honestly. Your participation is voluntary, and your answers will be kept private. If you are a parent/guardian and your child is under the age of 12, please complete this form for them and skip questions about veteran status, sexual orientation, and current gender identity. Thank you!
Organization Name
Date of Activity
-
Month
-
Day
Year
Date
Overall, how would you rate your mental wellbeing before you came to this activity/event?
1 - I was feeling pretty stressed, anxious, sad and/or depressed
2 - I was feeling somewhat stressed or sad, but managing
3 - I was OK
4 - I was feeling pretty good
5 - I was feeling great
How are you feeling after participating in this arts/cultural activity?
1 - A lot worse
2 - Worse
3 - About the same
4 - Better
5 - A lot better
Did this activity help you get out of your head or deal with stress?
1 - Not at all
2 - Not really
3 - Yes, a little
4 - Yes, a lot
What did this experience do for you? (check all that apply)
Helped me feel happy or joyful
Helped me relax or calm down
Let me express myself
Took my mind off things
Made me feel more confident
Other
If you selected "Other" above, please describe:
Did this activity share information on where to go for mental health help in Ventura County?
1 - No
2 - Not sure
3 - Yes, a little
4 - Yes, definitely
Did this activity help you make sense of or work through your feelings?
1 - Not at all
2 - Not really
3 - Yes, a little
4 - Yes, a lot
Did this activity help you better understand something about yourself or your past?
1 - Not at all
2 - Not really
3 - Yes, a little
4 - Yes, a lot
In your own words, please share how this arts/cultural activity made you feel?
Did this activity help you connect with others or feel less alone?
1 - Not at all
2 - Not really
3 - Yes, a little
4 - Yes, a lot
I experienced it alone
What did you get out of this activity that you don't usually get from other experiences:
Would you participate in an activity like this again when you're feeling stressed, anxious, or sad?
1 - No
2 - Probably not
3 - Maybe
4 - Definitely
Any other thoughts you'd like to share?
Age
Under 13
14 - 18
19 - 25
26 - 35
36 - 45
46 - 55
56 - 65
66 and over
How do you describe your gender?
Female
Male
Non-binary
Prefer not to say
Prefer to self-describe
If you selected "Prefer to self-describe" above, please describe:
What is your race/ethnicity?
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino/a/x
Native Hawiian or Pacific Islander
White
Prefer not to say
Prefer to self-describe
If you selected "Prefer to self-describe" above, please describe:
Zip Code:
Submit
Should be Empty: