Upstream Committee Wellness Check-In

Statement of Purpose

Having a variety of opportunities to interact with other people can help improve the quality of our lives. Feeling connected to others and having a sense of belonging can be tough, especially nowadays. Please complete this short survey to share your opinion about creative ways we can interact more with other people. Thank you!

If you are in need of support please contact Riverside County Help Line at 951-686- (HELP) 4357.

Question Title

On a scale of 1-10 how satisfied are you with your own sense of connection to others?

1 (Not Satisfied)

5 (Somewhat Satisfied)

10 (Very Satisfied)

Clear

i We adjusted the number you entered based on the slider’s scale.

Question Title

Do you feel a part of a larger community?

Yes

Question Title

If you selected no, which of the following are true. (SELECT ALL THAT APPLY)

I do not feel alone

I lack companionship

I am no longer close to anyone

I feel a part of a small group of friends

I am unhappy being so withdrawn

I can't find companionship when I want it

Other (please specify)

Question Title

Name some things or activites you do that have helped you to remain hopeful during this pandemic.

Question Title

If you could share some advice with others on ways to increase their hope and gratitude during tough times, what would it be?

Question Title

Would you like to speak or share with others such as the youth?

Yes

Not sure

Upstream Committee Wellness Check-In

Statement of Purpose

Question Title

On a scale of 1-10 how satisfied are you with your own sense of connection to others?

Question Title

Do you feel a part of a larger community?

Question Title

If you selected no, which of the following are true. (SELECT ALL THAT APPLY)

Question Title

Name some things or activites you do that have helped you to remain hopeful during this pandemic.

Question Title

If you could share some advice with others on ways to increase their hope and gratitude during tough times, what would it be?

Question Title

Would you like to speak or share with others such as the youth?

Question Title

Do you have any other comments, questions, or concerns? If so, share them below.

Question Title

Age:

Question Title

I am a family caregiver:

Question Title

Optional:

Question Title

Do we have permission to share your comments and answers anonymously?

Upstream Committee Wellness Check-In

Statement of Purpose

Question Title

* On a scale of 1-10 how satisfied are you with your own sense of connection to others?

Question Title

* Do you feel a part of a larger community?

Question Title

* If you selected no, which of the following are true. (SELECT ALL THAT APPLY)

Question Title

* Name some things or activites you do that have helped you to remain hopeful during this pandemic.

Question Title

* If you could share some advice with others on ways to increase their hope and gratitude during tough times, what would it be?

Question Title

* Would you like to speak or share with others such as the youth?

Question Title

* Do you have any other comments, questions, or concerns? If so, share them below.

Question Title

* Age:

Question Title

* I am a family caregiver:

Question Title

* Optional:

Question Title

* Do we have permission to share your comments and answers anonymously?

On a scale of 1-10 how satisfied are you with your own sense of connection to others?

Do you feel a part of a larger community?

If you selected no, which of the following are true. (SELECT ALL THAT APPLY)

Name some things or activites you do that have helped you to remain hopeful during this pandemic.

If you could share some advice with others on ways to increase their hope and gratitude during tough times, what would it be?

Would you like to speak or share with others such as the youth?

Do you have any other comments, questions, or concerns? If so, share them below.

Age:

I am a family caregiver:

Optional:

Do we have permission to share your comments and answers anonymously?