Individual’s Participation Information & Evaluation
ProActive Caring
Mindfulness Strategies & Meditations
Trainers to complete with each participant

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* 1. Trainer Information

Full Name

Company

Email Address

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* 2. How many of the tools did you use with this individual?

# of strategies

# of meditations

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* 3. What went well/is there a success story?

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* 4. Comments on tools and use with this person:

Individual/Participant Information (please complete this section FOR the individual)

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* 5. First Name Only

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* 6. Gender:

Male

Female

Other

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* 7. Age range:

0-2

3-5

6-11

12-14

15-18

19-26

27+

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* 8. The area where I live is:

Urban

Suburban

Rural

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* 9. My ethnicity is:

Hispanic or Latino

Not Hispanic or Latino

Undisclosed

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* 10. My race is:

White or Caucasian

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Two or more races

Undisclosed

Individual/Participant Information (please complete this section WITH the individual/ABOUT the individual, based on your observations)

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* 11. I liked this

Very much

A little bit

Not at all

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* 12. I felt good

Most of the time

A little

Not at all

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* 13. I want to keep using what I learned

Yes

Maybe

Now that I’ve learned this: (please complete this section WITH the individual/ABOUT the individual, based on your observations)

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* 14. I feel like I can say what I want better

Yes

Maybe

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* 15. I will be a better self-advocate

Yes

Maybe

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* 16. I will speak up in meetings with school or care team

Yes

Maybe

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* 17. Do you (the individual) serve in a leadership or advocacy position regarding disabilities (coalition, policy board, advisory board)?

Yes

If you have questions or other feedback, please contact:

Valerie Capalbo, LCSW
Project Administrator
845-661-3859
vcapalbo.proactivecaring@gmail.com