2019 Peer Support Intake Survey

How did you find our program?

This survey has 16 questions to help us improve our peer support program.

Question Title

* 1. What has been your engagement so far with Poetry for Personal Power? (pick all that apply)

Want to learn more

None

Just heard about the program

Online fan through website or Facebook only

Incoming Peer Support person

Audience member at one show

Audience member at multiple shows

What would you like to know about Poetry for Personal Power?

Question Title

* 2. How did you hear about the Poetry for Personal Power peer support program? (pick all that apply)

Heard about it from a Poetry for Personal Power staff person

Heard in a support group

Referred through other social service organizations

Saw it on social media

Other advocacy organization referral

Email notification

Not sure how I heard about it

Heard about it from my peer support provider

Tell us more about what is working in our marketing.

Question Title

* 3. How are you going to pay for peer support?

I would like free peer support (foundation pay - only in KC).

I am willing to pay my peer specialist what I make per hour for one hour of support. (private pay - in all regions)

I need to discuss payment with Poetry for Personal Power staff.

What other questions do you have related to peer support payment or costs?

Question Title

* 4. Which of our program areas interest you (pick all that apply).

Healthcare messaging (talking about health topics at poetry slams)

Artist entrepreneur development

Providing peer support with community outreach and networking

Mental health and substance use recovery advocacy

Something else

Other (please specify)

Question Title

* 5. Which community activities do you already participate in? (more than twice a month).

Exercise or sport activity

Church, synagogue, or other spiritual community

Entrepreneurship or business development

Mental health and substance use recovery advocacy

Racism reduction advocacy

LGBTQ community advocacy

Arts community

Nature, gardening, or outdoor activities

I don't do much yet

Which of these would like to do more of?

Question Title

* 6. Your Contact Info

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 7. Unique Client Identifier: What is the last four digits of your phone number right now? This will be your unique client Identifier for our program. Keep this same number as long as you use our program even if your phone number changes.