Pre-Program Survey
A survey to help us understand your experience and goals before starting the program.
Name
*
What name would you like us to use during the program?
What pronouns do you use?
How long have you been living with chronic illness or chronic pain?
Less than 1 year
1 to 3 years
3 to 5 years
5 to 10 years
10+ years
What brings you to this community?
On a scale from 1 to 10, how much do you agree with these statements? (1 = Not at all, 10 = Completely)
Rows
I feel connected to my body
I trust my body
I feel hopeful about my future
I feel understood by people around me
I have a supportive community
I have tools that help me regulate my nervous system
I know how to respond to stress in a way that feels supportive
I experience moments of joy or pleasure regularly
1
2
3
4
5
6
7
8
9
10
When you think about living with chronic illness or pain, what feels hardest right now? (Select up to three)
Isolation
Grief
Anxiety
Body mistrust
Fatigue
Pain
Shame
Identity changes
Relationships
Feeling misunderstood
Not knowing how to regulate
Something else
If this program is successful for you, what do you hope will be different by the end?
Is there anything you would like me to know before we begin?
Submit
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