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Pre-Screening Questionnaire: Building Trust Between Black Clients and White Therapists in Therapy

1.In what year were you born?
2.What personal or cultural experiences have shaped your racial identity as a Black or African-American person?
3.In general, how would you rate your overall mental or emotional health?
4.When and for how long did you receive mental health treatment from a White mental health provider?
5.You must be available for a 90-minute interview, which can be held in-person, via video conferencing (e.g. Zoom, Google Meet, Microsoft Teams), or by phone, at a time that suits you, and willing to provide additional information as needed for up to 14 days after the interview. What potential barriers could hinder your ability to meet this requirement?
6.What is your gender identity?
7.What is the highest level of education you have completed?
8.What is your approximate annual income?
9.In what state or U.S. territory do you live?
10.What is your preferred method of contact? To discuss your participation in the study further, please provide your preferred contact information, such as your email address and/or telephone number.