The Binti Circle Support Group Questionnaire
The survey will take approximately 4 minutes to complete.
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Email *
Name *
Mailing Address *
City *
State *
Email Address *
Phone Number *
T-Shirt Size *
Which generation are you? *
Who do/did you care for? *
 Are you still caring for your mother/father/parents?
*
What is/was your caregiving role?
 *
How long have you been caring for, or did you care for your mother/father/parents? *
 *
Where does/did your mother/father/parents live?
*
Please rate your level of satisfaction with the following:
Quality of Life *
Very Satisfied
Very Dissatisfied
Mental Health including Mood *
Very Satisfied
Very Dissatisfied
Social Activities and Relationships *
Very Satisfied
Very Dissatisfied
Which of the following would you like to experience in "The Binti Circle"? 
 *
Would you like to assist with the following?
 *
Required

What other ideas, discussion topics, etc. do you have for "The Binti Circle"?

Are you available to meet every 4th Friday of the month?
 *
WhatsApp is the group chat communication that we use. Do you have WhatsApp (group chat app)?
*
How did you learn about the Binti Circle? *

If a Binti Circle member or someone else referred you, please provide their name.

Any other feedback you would like to provide?
Thank you for completing the intake form! We will be in touch within 24-72 hours to welcome you to the Binti Circle! 
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