TAIBU Healing Circles Project
1.
What is your first name?
2.
How old are you?
12 and under
13 - 17
18 - 24
25 -34
35 - 54
55 to 64
65 and older
3.
Where do you live? (For example, Toronto, Mississauga, Scarborough, Ajax)
4.
Do you identify as Black?
Yes
No
5.
What is your background?
African
African-American
Canadian
Caribbean/West Indian
Franco-africain(e)
Other (please specify)
6.
Have you accessed any mental health services in the last 6 months- 12 months?
7.
How would you describe your experiences accessing mental health services?
8.
As a Black person, what do you need to support your mental health?
9.
Are you a service provider who
identifies as Black
serves Black communities
identifies as Black and serves Black communities
I am not a service provider
10.
Have you ever participated in a healing circle?
Yes
No
11.
Would you be comfortable participating in a healing circle?
Yes
No
12.
If you are interested in participating in TAIBU's Healing Circle Project please attach your contact information in the space provided.
