Devine Youth Inc. Program Interest Survey

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* 1. At what email address would you like to be contacted?

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* 2. What town do you reside?

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* 3. Children's Ages

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* 4. Are you and or your child currently using any formal mental health related services? (For example, receiving counseling, guidance, or help with something in your life from a professional or semi-professional provider.)

Yes

No

Both

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* 5. Would you be interested in the following FREE youth programs?

Free Virtual Youth Art Program (we mail all the supplies monthly)

Free Virtual Youth Book Club ( we send the books monthly to read)

Free Healthy weekly snack program we drop off the snacks.

Virtual Teen Bullying Support Group (Small Fee Required)

Other (please specify)

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* 6. Would you agree to take stress or other rating scale survey before each program?

Yes

No

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* 7. Would you be willing to take a program feedback survey at the end of the program?

Yes

No

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* 8. Would you be willing to complete the entire program or attend for at least 3 months?

Yes

No

Other (please specify)

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* 9. Would you be willing to take your child to 1 or 2 outside activities?

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* 10. Have you attended a Devine Youth Event before?

Yes

No