Survey
Age
I am:
Have you experienced any of the following in the past year?
On a scale of 1-5, with 1 being not very bothered and 5 being very bothered, how bothered are you by the above issues?On a scale of 1-5, with 1 being not very bothered and 5 being very bothered, how bothered are you by the above issues?
Have you received treatment for the above issues in the past?
Was treatment helpful?
Would you be interested in pursuing treatment for these issues?
What would be most important to you abut the treatment you recive? Please check up t 3 answers:
What treatment model would be most appealing to you at this time?
If you re not intrested in pursuing treatmen at this time, what barriers are currently standig in your way?