Support Network Assessment
Help us understand your support network by answering the questions below. Your responses will guide us in providing better resources and assistance.
Your Full Name
*
First Name
Last Name
Your Age
*
What is your primary relationship status?
*
Single
Married/Partnered
Divorced/Separated
Widowed
Other
Who are the main sources of support in your life? (Select all that apply)
*
Family members
Friends
Colleagues/Classmates
Neighbors
Support groups
Community organizations
Healthcare professionals
Other
How often do you receive support from your network?
*
Daily
Several times a week
Weekly
Monthly
Rarely
Never
Please rate your satisfaction with the following types of support you receive:
*
Rows
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
Emotional support (listening, encouragement)
1
2
3
4
5
Practical support (help with tasks, errands)
6
7
8
9
10
Informational support (advice, guidance)
11
12
13
14
15
Financial support
16
17
18
19
20
Social companionship
21
22
23
24
25
On a scale of 1 to 10, how easy is it for you to access support when needed? (1 = Very difficult, 10 = Very easy)
*
Very difficult
1
2
3
4
5
6
7
8
9
Very easy
10
1 is Very difficult, 10 is Very easy
Have you experienced any barriers in accessing support from your network?
*
Yes
No
If yes, please describe the barriers you have experienced.
In what areas do you feel you need more support? (Select all that apply)
*
Emotional well-being
Physical health
Work/School
Finances
Family/Relationships
Social life
Other
Please share any additional comments or suggestions about your support network.
Submit Assessment
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