Mental Health Strong - New Member Form

This brief survey is to help us understand the background of each person in the support group, identify trends and potential research before one learns the Mental Health Strong tools. Your personal information is confidential, will not be shared outside MHS and is gathered only to add you to the MHS communications that you can at any point opt out of. Thank you again for your valuable input so that we can continuously bring hope, resources and support to marriages with mental health and addiction challenges.

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* 1. Name

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* 2. Email

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* 3. Phone Number

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* 4. What are your social media handles?

Facebook

Instagram

Twitter

Other

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* 5. Where do you live in general? (State, Country)

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* 6. Do you have children?

Yes

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* 7. How long have you been married?

0-5

6-10

11-20

21-30

31+

Not married - dating

Engaged

Divorced from spouse with mental health or addiction challenge

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* 8. What condition(s) or addictions does your spouse have (click all that apply)?

ADHD

Anxiety Disorder

Autism Spectrum Disorder

Bi-polar Disorder

Depression Disorder

Obsessive Compulsive Disorder

Other Personality Disorder

Panic Disorder

Phobia Disorder

Post Traumatic Stress Disorder

Schizophrenia

Suicidal Thoughts

Alcohol Addiction

Drug Addiction

Food Addiction

Sexual Addiction

Video game Addiction

Hasn't been formally diagnosed yet

Other (please specify)

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* 9. What stage of the marriage are you in wiith a mental health or addiction challenge?

Crisis (in crisis whether spouse in hospitalization, mania, jail, verge or in separation, divorce, abuse, affair, etc.)

Surviving (you and your spouse are just existing with one another and not managing the condition as the "elephant in the room")

Growing (you and your spouse are aware of the condition and impacts; taking two steps forward and one step back)

Thriving (you and your spouse are living your best life despite the conditions - this is rare)

Relapse (you or your spouse are relapsing in behaviors/choices that hinder health and the relationship)

Other (please specify)

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* 10. On a scale of 1-5, how hopeful and skilled do you feel about your marriage making it and not obtaining a divorce?

1 - Not going to make it (I am on my last strand with no hope, resources & support)

2 - Not likely going to make it (I have some tools but it seems to be a one sided relationship)

3 - Not sure (We are just existing)

4 - Likely going to make it (As long as my spouse manages his/her condition or addiction)

5 - Confident that we are going to make it (We both have the tools, resources and support)

Other (please specify)

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* 11. What is your faith (it is ok if you don't have one)?

Agnostic

Athiest

Buddhist

Christian

Hindu

Jewish

Mormon

Muslim

No faith

Other (please specify)

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* 12. What is the main item that you are looking to gain from the MHS Community?

Empathy with not feeling so alone

Hope

Learn about marriage with mental health & addiction

Learn new facts and data

Listening to others

New Friends

Prayer

Sharing life together

Support

Tools and resources

Other (please specify)

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* 13. How did you hear about Mental Health Strong?

Know Erin or Keith

Friend

Mental Health Strong Communication

Mental Health Strong Book

Mental Health Clinician, Therapist or Psychiatrist

Social Media

Church or Church Ministry

NAMI

Podcast

IOCDF

Meetup

Fresh Hope

Change My Relationship

Other (please specify)

Mental Health Strong - New Member Form

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* 1. Name

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* 2. Email

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* 3. Phone Number

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* 4. What are your social media handles?

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* 5. Where do you live in general? (State, Country)

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* 6. Do you have children?

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* 7. How long have you been married?

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* 8. What condition(s) or addictions does your spouse have (click all that apply)?

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* 9. What stage of the marriage are you in wiith a mental health or addiction challenge?

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* 10. On a scale of 1-5, how hopeful and skilled do you feel about your marriage making it and not obtaining a divorce?

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* 11. What is your faith (it is ok if you don't have one)?

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* 12. What is the main item that you are looking to gain from the MHS Community?

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* 13. How did you hear about Mental Health Strong?

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* 14. Additional Comments / Suggestions / Needs / Questions