Wellness Support Group Screening Survey

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* 1. Are you a current SRM patient?

Yes

If you answered no, would you be interested in a support group for non-SRM patients in the future?

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* 2. Have you ever participated in a support group?

Yes

If yes, please share more about your experience.

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* 3. Are you comfortable sharing on camera in a group zoom call?

Yes

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* 4. In order to help us tailor the group to your needs, check all that apply:

Primary infertility

Secondary infertility

LGBTQIA+

Single parent by choice

3rd party reproduction

History of reproductive loss

Other (please specify)

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* 5. Describe a typical day of your eating habits (meals, snacks, beverages)

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* 6. Over the last two weeks, how often have you been bothered by the following problems: Feeling nervous, anxious or on edge?

Not at all

Several days

More than half the days

Nearly every day

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* 7. Over the last two weeks, how often have you been bothered by the following problems: Not being able to stop or control worrying?

Not at all

Several days

More than half the days

Nearly every day

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* 8. Over the last two weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things?

Not at all

Several days

More than half the days

Nearly every day

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* 9. Over the last two weeks, how often have you been bothered by the following problems: Feeling down, depressed or hopeless?

Not at all

Several days

More than half the days

Nearly every day

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* 10. Which time of day works best for you to meet for a one-hour support group session?

Morning

Noon

Early afternoon

Wellness Support Group Screening Survey

Question Title

* 1. Are you a current SRM patient?

Question Title

* 2. Have you ever participated in a support group?

Question Title

* 3. Are you comfortable sharing on camera in a group zoom call?

Question Title

* 4. In order to help us tailor the group to your needs, check all that apply:

Question Title

* 5. Describe a typical day of your eating habits (meals, snacks, beverages)

Question Title

* 6. Over the last two weeks, how often have you been bothered by the following problems: Feeling nervous, anxious or on edge?

Question Title

* 7. Over the last two weeks, how often have you been bothered by the following problems: Not being able to stop or control worrying?

Question Title

* 8. Over the last two weeks, how often have you been bothered by the following problems: Little interest or pleasure in doing things?

Question Title

* 9. Over the last two weeks, how often have you been bothered by the following problems: Feeling down, depressed or hopeless?

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* 10. Which time of day works best for you to meet for a one-hour support group session?

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* 11. Please leave your name, a good contact phone number AND let us know what time of day typically works best for you for a phone call.