Social Connection Feedback Form
Share your experiences and opinions about your social connections to help us foster a more connected community.
Your Full Name (optional)
First Name
Last Name
Your Age
*
Gender
Female
Male
Non-binary
Prefer not to say
Other
How often do you interact with others socially (in person or online)?
*
Daily
A few times a week
Once a week
A few times a month
Rarely
How satisfied are you with your current level of social connection?
*
Not satisfied at all
1
2
3
4
Very satisfied
5
1 is Not satisfied at all, 5 is Very satisfied
Please rate your sense of belonging within your community.
*
1
2
3
4
5
What are the main barriers you face in building or maintaining social connections? (Select all that apply)
*
Lack of time
Shyness or social anxiety
Lack of opportunities or events
Transportation or distance
Not feeling welcomed
Other
Which methods do you prefer for connecting with others? (Select all that apply)
*
In-person gatherings
Online groups or forums
Social media
Phone or video calls
Community events
Other
Please indicate your agreement with the following statements about your social experience.
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel connected to others.
1
2
3
4
5
I have someone to talk to when I need support.
6
7
8
9
10
I participate in community activities.
11
12
13
14
15
I feel lonely.
16
17
18
19
20
How do your social connections impact your overall well-being?
*
What suggestions do you have to improve social connection opportunities in your community?
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