Loneliness Support Check-In Form
Welcome to the Loneliness Support Check-In Form. Please answer the following questions to help us understand how you’re feeling and how we can best support you.
First Name
*
How are you feeling today?
*
Hopeful
Okay
Lonely
Struggling
Prefer not to say
How often have you felt lonely in the past week?
*
Rarely
Sometimes
Often
Almost always
Would you like someone to reach out to you?
*
Yes
No
Maybe
Preferred method of support
Phone call
Email
Text message
Group chat
No preference
Is there anything specific you’d like to talk about or get support with?
Do you have a supportive person or group you can connect with?
Yes
No
Not sure
What is one thing that helped you feel less lonely recently?
What is your age group?
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Prefer not to say
Email address (optional, if you’d like us to follow up)
example@example.com
Submit Check-In
Should be Empty: