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Home
Services
About
Booking
Contact
Mindfulness Products
Online Courses
Event Listings
Living Well: Return to Centre Registration
The Pause Practice Registration
Search
Community of Minds
Thank you for helping to bridge the gap.
If you are at risk of harm to yourself or others contact Here 24/7 -
1 844 437 3247 -
you are not alone.
This number is manned by fully trained counselors and crisis workers who are kind gentle and supportive.
*
Indicates required field
If you wish to not give your name please type none.
*
First
Last
Please type your email here. If you do not wish to give your email please type
[email protected]
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What age are you?
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Under 10
10-15
16-19
20-25
25-30
30-35
35-40
40-50
50-60
60-70
70-80
80-90 and up
Have you been diagnosed with a mental health disorder?
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What have you been diagnosed with? Check all that applies
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Anxiety
Depression
Bipolar
Schizophrenia
ADHD or ADD
Mood disorder
PTSD
Addiction
OCD
Eating disorder
Other
Please add details if you typed other.
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Please add any details that you are comfortable sharing about your diagnosis.
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What age were you diagnosed or that you discovered you had this condition?
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Under 5
Under 10
Under 15
15-20
20-30
30 and up
Other
If Other please specify:
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To help people truly understand what mental health feels like for others please take time here to explain how it is for you. By collating this information I hope to allow others better understanding of mental health and for people with mental health disorders to feel less alone and more supported. Please check all that applies to you.
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Mind racing
Repetitve thoughts
Ruminating
Shaking
Sweating
Sense of electric shocks
Fear
Lonely
Guilt
Shame
Confusion
Stomach aches
Headaches
Claustraphobic
Stuttering
Fear of being alone
Night terrors
Grief
Rage
Crying
Anger
Social situations overwhelming
Self-sabbotage
Low self-esteem
Hears voices
Dissociation
Self-harm
Suicical thoughts
Irritable
Hoplessness
Other
If other please add details or type 0
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What support services have worked best for you? Check all that applies
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CMHA
Doctor
Counselling
Psychiatrist
Psychologist
CBT
DBT
Medication
Hypnosis
EFT
Acupuncture
Rehab
Naturopath
Homeopath
Energy healer
Neurofeedback
Other
If other please add details. If not please type none.
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Do you feel there is enough support for people facing mental health challenges?
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Yes
No
Do you feel there is enough infomation for families supporting those with mental health challenges?
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Yes
No
Other
Please add details or type none.
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Where would you like to see more support or information? Check all that applies
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Radio
Social media
Schools
Doctors offices
Workplace
News
Other
Please add details or type none.
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Do you know your support options for when you are in need?
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Yes
No
Unsure
How often do you feel misunderstood?
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Several times a day
One or two times a day
Several times a week
A few times a week
Occasionally
Unsure
How often do you feel lonely?
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Daily
Occasionally
All the time
Unsure
Check any statements that relate to you. Check all that applies
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I wish people to know who I really am
I want people to see me for who I am not just my mental health
I want people to stop and listen to me
I don't feel heard
I don't feel seen
People don't understand how hard it is for me
I have to work hard to keep people from seeing that I am struggling
I feel ashamed
I feel misunderstood
It is ok to have mental health challenges
I am fully supported
I talk openly about my mental health
I want to help others
I am open to help
It is ok that some days are harder than others
I have the tools to handle my mental health
None of the above
Please add any details here.
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What tools help you the most? Check all that applies
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Breathing techniques
Meditation
Mindfulness outlets
Exercise
Family and friends
Music
Art
Nature
Pets
Other
Please add any details or type none.
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What would you like people to know about mental health?
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When you are struggling what is it useful for loved ones or people to know about you? Check all that applies.
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My behaviour is often a cover up for my mental health
Really all I need is reassurance
Ask me how you can help
Please don't take my emotion and behaviour personally
Don't be scared of my mental health
Please take time to learn more my mental health
Please get support for yourself so you have the tools to cope
Addiction isn't a sign of weakness
Please see me for more than just my mental health
Let's come up with a plan to support us all better
Other
Please add details or type none
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How would others know you are struggling?
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Shakey
Stuttering
Pulling at hair or clothes
Excessive talking
Quiet
Excessive laughter
Chewing inside of cheek
Jiggling knee or legs
Not responding to calls or texts
Racing or distorted conversations
Mood swings
Asking for money
Eye avoidance
Other
Please add details here or type none
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If people or loved ones notice that you are struggling what do you prefer? Please check all that applies.
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It is best to give me space
Please do not draw attention to me or the fact that I am struggling
A hug or physical contact helps
Talking to me in a quiet voice helps
Reminding me to use tools might help
Diverting my attention helps
Making sure I use my medication or support tools might help
Let me deal with it myself is best
I am best left alone
Other
If other please add details or type none.
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Is there anything you would like to add? Please add details or type none.
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Is there anything you feel could have been asked in this questionnare that has not been? Please add details or type none.
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Would you be interested in completing another form for this project?
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Yes
No
Would you be interested in being interviewed in the future for this project?
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Yes
No
Would you like access to mental health support infomation?
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Yes
No
A free monthly support and wellness group is being started in Guelph in January. Is this something that is of interest for you or a support member?
*
Yes
No
If yes please add contact info here or visit Mandalia House of Healing on Facebook for updates.
*
If you are at risk of harm to yourself or others contact Here 24/7 -
1 844 437 3247 -
you are not alone.
This number is manned by fully trained counselors and crisis workers who are kind gentle and supportive. This call center is for any age and for carers and people facing mental health challenges and or crisis. If you have questions about yourself or a loved one please do not hesitate to call.
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Home
Services
About
Booking
Contact
Mindfulness Products
Online Courses
Event Listings
Living Well: Return to Centre Registration
The Pause Practice Registration
