Berks County Suicide Prevention Task Force... RUOK Berks

Suicide Prevention Task Force Wellness Bag Survey

On behalf of the Berks County Suicide Prevention Task Force we want you to know that we care, and that mental illness is treatable and suicide is preventable. Please take a few minutes to offer some feedback about the contents of the wellness bag. If you would like to be entered in the free gift card drawing, please provide contact information below. Any information that you are willing to provide is very helpful to us.

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* 1. Wellness Bag Recipients Information:

Name (optional):

Your age:

E-mail address:

Agency/Occupation:

Mailing address:

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* 2. Overall Impression of the Wellness Bag

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 3. Self Care Journals

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 4. Fidget Spinner

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 5. Lip Balm

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 6. Coloring Books/Pencils

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 7. Coloring Book/Pencils

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 8. Toss and Splat Ball

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 9. Playing Cards

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 10. Love Me Cards

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

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* 11. Bouncing Putty

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

1= Not Helpful

2= Slightly Helpful

3= Helpful

4= Very Helpful

5= Extremely Helpful

Berks County Suicide Prevention Task Force... RUOK Berks

Suicide Prevention Task Force Wellness Bag Survey

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* 1. Wellness Bag Recipients Information:

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* 2. Overall Impression of the Wellness Bag

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* 3. Self Care Journals

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* 4. Fidget Spinner

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* 5. Lip Balm

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* 6. Coloring Books/Pencils

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* 7. Coloring Book/Pencils

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* 8. Toss and Splat Ball

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* 9. Playing Cards

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* 10. Love Me Cards

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* 11. Bouncing Putty

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* 12. Can you recommend any additional items to put in the bag for someone who is struggling with their mental wellness

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* 13. Any Other Comments