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Individual’s Participation Information & Evaluation
ProActive Caring
Mindfulness Strategies & Meditations
Trainers to complete with each participant
1.
Trainer Information
Full Name
Company
Email Address
2.
How many of the tools did you use with this individual?
# of strategies
# of meditations
3.
What went well/is there a success story?
4.
Comments on tools and use with this person:
Individual/Participant Information
(please complete this section
FOR
the individual)
5.
First Name Only
6.
Gender:
Male
Female
Other
7.
Age range:
0-2
3-5
6-11
12-14
15-18
19-26
27+
8.
The area where I live is:
Urban
Suburban
Rural
9.
My ethnicity is:
Hispanic or Latino
Not Hispanic or Latino
Undisclosed
10.
My race is:
White or Caucasian
Black or African American
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Two or more races
Undisclosed
Individual/Participant Information
(please complete this section
WITH
the individual/
ABOUT
the individual, based on your observations)
11.
I liked this
Very much
A little bit
Not at all
12.
I felt good
Most of the time
A little
Not at all
13.
I want to keep using what I learned
Yes
Maybe
No
Now that I’ve learned this:
(please complete this section
WITH
the individual/
ABOUT
the individual, based on your observations)
14.
I feel like I can say what I want better
Yes
Maybe
No
15.
I will be a better self-advocate
Yes
Maybe
No
16.
I will speak up in meetings with school or care team
Yes
Maybe
No
17.
Do you (the individual) serve in a leadership or advocacy position regarding disabilities (coalition, policy board, advisory board)?
Yes
No
If you have questions or other feedback, please contact:
Valerie Capalbo, LCSW
Project Administrator
845-661-3859
vcapalbo.proactivecaring@gmail.com
Current Progress,
0 of 17 answered
