Families Matter

New Glasgow Fall 2020





Is it okay to leave a phone message?
 Yes    No


How do you identify your cultural background?
This information will increase our awareness of specific cultural concerns and practices, and help us identify who we are reaching with this program.

 Aboriginal
 African Nova Scotian
 Caucasian
 Francophone
 New immigrant
 Other:

The person with a mental health/addiction problem or illness is your:
 Child
 Parent
 Sibling
 Spouse/Partner
 Friend
 Other:

Age of the person you are supporting
 Under 19
 19-30
 31-40
 41-50
 51-60
 61+

What is the mental health/addiction problem or illness? Please check all that apply:
 Psychosis  
 Schizophrenia  
 Schizo-affective disorder  
 Drug/alcohol addiction/gambling or gaming  
 Bipolar disorder  
 Depression  
 Anxiety Disorder  
 Obsessive Compulsive Disorder  
 Personality disorder  
 Undiagnosed  
 Other:  

How did you hear about this program?
 Poster
 Internet
 Community Health Team
 Family Doctor
 Mental Health Professional
 Friend
 Family Member
 Community Organization
 Other:

Do you consent to being contacted within the next 12 months for a follow up evaluation?
 Yes    No