Support Group Assessment

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10Questions

1
What is your name?
First Name
Last Name
2
What is your date of birth?
3
What is your gender?
Female
Male
Other
Prefer not to say
4
What is your racial category?Circle as many as apply.
American Indian / Alaska Native
Asian
Black / African-American
Hispanic / Latino
Native Hawaiian / Other Pacific Islander
White / Caucasian
Prefer not to say
Other
5
What is your primary language?
6
How long have you been in this group?
7
How do you normally attend group?
In-Person
via Telehealth
8
In the past three weeks did you...Part One
Not at all
Sometimes
Moderately
Mostly
All the Time
Find it hard to leave your home?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Find telehealth sessions difficult in any way?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Attend a group each week?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Meet with the dietitian?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Talk to your Therapist?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Meet with the Physician?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Find it hard to leave your home?
Find telehealth sessions difficult in any way?
Attend a group each week?
Meet with the dietitian?
Talk to your Therapist?
Meet with the Physician?
Not at all
Row 0, Column 0
Sometimes
Row 0, Column 1
Moderately
Row 0, Column 2
Mostly
Row 0, Column 3
All the Time
Row 0, Column 4
Not at all
Row 1, Column 0
Sometimes
Row 1, Column 1
Moderately
Row 1, Column 2
Mostly
Row 1, Column 3
All the Time
Row 1, Column 4
Not at all
Row 2, Column 0
Sometimes
Row 2, Column 1
Moderately
Row 2, Column 2
Mostly
Row 2, Column 3
All the Time
Row 2, Column 4
Not at all
Row 3, Column 0
Sometimes
Row 3, Column 1
Moderately
Row 3, Column 2
Mostly
Row 3, Column 3
All the Time
Row 3, Column 4
Not at all
Row 4, Column 0
Sometimes
Row 4, Column 1
Moderately
Row 4, Column 2
Mostly
Row 4, Column 3
All the Time
Row 4, Column 4
Not at all
Row 5, Column 0
Sometimes
Row 5, Column 1
Moderately
Row 5, Column 2
Mostly
Row 5, Column 3
All the Time
Row 5, Column 4
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9
In the past three weeks did you...Part Two
Not at all
Sometimes
Moderately
Mostly
All the Time
Practice self-care?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Participate in the group activity?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
Accomplish one goal from your treatment plan?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
Did you complete your homework assignment each week?
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Did you use your coping skills that were taught in the group?
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Did you keep track of when you used your coping skills outside of the group?
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Did you find the workbook sections helpful?
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Practice self-care?
Participate in the group activity?
Accomplish one goal from your treatment plan?
Did you complete your homework assignment each week?
Did you use your coping skills that were taught in the group?
Did you keep track of when you used your coping skills outside of the group?
Did you find the workbook sections helpful?
Not at all
Row 0, Column 0
Sometimes
Row 0, Column 1
Moderately
Row 0, Column 2
Mostly
Row 0, Column 3
All the Time
Row 0, Column 4
Not at all
Row 1, Column 0
Sometimes
Row 1, Column 1
Moderately
Row 1, Column 2
Mostly
Row 1, Column 3
All the Time
Row 1, Column 4
Not at all
Row 2, Column 0
Sometimes
Row 2, Column 1
Moderately
Row 2, Column 2
Mostly
Row 2, Column 3
All the Time
Row 2, Column 4
Not at all
Row 3, Column 0
Sometimes
Row 3, Column 1
Moderately
Row 3, Column 2
Mostly
Row 3, Column 3
All the Time
Row 3, Column 4
Not at all
Row 4, Column 0
Sometimes
Row 4, Column 1
Moderately
Row 4, Column 2
Mostly
Row 4, Column 3
All the Time
Row 4, Column 4
Not at all
Row 5, Column 0
Sometimes
Row 5, Column 1
Moderately
Row 5, Column 2
Mostly
Row 5, Column 3
All the Time
Row 5, Column 4
Not at all
Row 6, Column 0
Sometimes
Row 6, Column 1
Moderately
Row 6, Column 2
Mostly
Row 6, Column 3
All the Time
Row 6, Column 4
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10
Did you find any of these questions hard to answer?
Yes
Somewhat
No
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