Quick Meeting Sign-in
The information you provide in this form is confidential. We require minimal basic detail in order to be able to contact you and to understand where, when and how our services are accessed. This helps us plan support where it is most needed and enables us to keep our services free.
Sign in to Google to save your progress. Learn more
Confidentiality (yours, ours & others) *
THIS IS A PRIVATE SUPPORT MEETING: You agree:(a) not to record this meeting in any way, (b) not to share anything from this meeting externally with others, (c) that if you are not here for personal support, you have both made this known to the facilitator and have obtained their permission to remain, (d) and that information provided herein can be used for funder performance reporting (ensuring that this service remains free to you) but that where this occurs, in order to protect you, it is provided only in anonymous format.
Meeting code *
3 character code that your facilitator will provide you (Facilitators only: https://bit.ly/2BerI8D)
Mobile *
We do not share this with anyone else. For safety reasons, we need a way to contact you.
Home postcode *
This helps us understand which locations need dedicated support
First name *
Let us know what to call you
In the last week, I have felt isolated *
3 = neutral / don't know
Strongly disagree
Strongly agree
In the last week, my situation has felt hopeless *
3 = neutral / don't know
Strongly disagree
Strongly agree
In the last week, I have felt suicidal *
3 = neutral / don't know
Strongly disagree
Strongly agree
These meetings help reduce my situational distress *
3 = neutral / don't know / not applicable
Strongly disagree
Strongly agree
What best describes you? *
Email Address? (Need only submit this once)
Any other comments? (max 160 characters)
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Parents Beyond Breakup. Report Abuse