No Wrong Door (Pre and Post Evaluation) - Hello, my name is ______________. I am contacting you from the Disability Network Wayne County Detroit.
Please rate how you feel TODAY about yourself, your living situation, your health, and your overall wellness.
Is this a Pre-Test or Post-Test for the program? *
First and Last Name *
What is your birthday including the year you were born? *
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What is your telephone number? *
What is your mailing address? *
What is your zip code?
What is your email address? *
What is today's date? *
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Do you currently (today) have access to a laptop, tablet, or computer to participate in an online program? *
Do you currently (today) have high speed internet access to participate in an online program? *
Do you need a tablet in order to participate?
Clear selection
Are you committed and interested in participating in a program online at least 3 times a week? *
Are you willing to communicate and share your feelings that you have experienced during this pandemic? *
What types of class would you be interested in? *
Required
Self-Assessment of Social Isolation? *
I do not agree
I agree, but it is not significant
I agree with this statement
I feel strongly about this statement
I am in total agreement with this statement
My Overall health is good....
I feel good about my current life situation....
My outlook on life is positive
I feel as though my health is improving....
I feel depression today.....
I have feelings of being overwhelmed....
I feel as though I am not going to make it....
I feel as though I do not have anyone to talk to.....
I feel as though I am completely alone....
I feel sad, gloomy, or weighed down today...
I am excited about life today.....
I feel as though I have good friends and relationships....
I am excited about my health situation...
I am in charge and control of my good health....
I feel as though I can make changes to improve my health...
During the past week, how many times did you do the following activities? *
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Talked to a friend or relative on the phone
Visited a friend in a social gathering
Engaged in a community or social event
Attended a virtual event or activity
Have you had Covid-19 in the last year? *
Have you been vaccinated for Covid-19? *
How has Covid-19 affected you? *
Do you ever run out of food or money to buy food before the end of the month? *
What type of health insurance do you currently have? Check all that apply? *
Required
Do you have any comments?
Name of Disability Network Wayne County Detroit Specialist *
Submit
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