SWX Acceptance Survey

Welcome to Struggle Well Experience. We’re glad you’re here.

Along your journey, we’ll ask you some questions. Your honest answers are critical to our collective success. We use them to gauge growth, understand the program impact, and ensure it meets the needs of our participants.

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Email Address*

Please enter the email address you used to apply for Struggle Well Experience. If you are unsure of your email, please ask the guide who has been assisting you in the application process to look it up and they will be happy to assist you.

First Name*

Please enter your first name

Last Name*

Please enter your last name

Please read each of the questions below and provide an answer to the best of your ability.

Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem and then select one of the options to indicate how much you have been bothered by that problem IN THE PAST WEEK. The options include; not at all, a little bit, moderately, quite a bit, and extremely.

Repeated, disturbing and unwanted memories of the stressful experience?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Repeated, disturbing dreams of the stressful experience?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling very upset when something reminded you of the stressful experience?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Avoiding memories, thoughts or feelings related to the stressful experience?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects or situations)?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Trouble remembering important parts of the stressful experience?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something wrong with me, no one can be trusted, the world is completely dangerous)?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Blaming yourself or someone else for the stressful experience or what happened after it?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Having strong negative feelings such as fear, horror, anger, guilt, or shame?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Loss of interest in activities that you used to enjoy?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling distant or cut off from other people?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Irritable behavior, angry outbursts, or acting aggressively?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Taking too many risks or doing things that could cause you harm?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Being "super alert" or watchful or on guard?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Feeling jumpy or easily startled?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Having difficulty concentrating?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Trouble falling or staying asleep?*

Not at all

A little bit

Moderately

Quite a bit

Extremely

Please read each statement and indicate how much the statement applied to you OVER THE PAST WEEK. There are no right or wrong answers. Do not spend too much time on any statement.

The below provides context to answer scale for reference: - Did not apply to me at all - NEVER, Applied to me to some degree, or some of the time - SOMETIMES, Applied to me to a considerable degree, or a good part of the time - OFTEN, Applied to me very much, or most of the time - ALMOST ALWAYS

I found it hard to wind down*

Never

Sometimes

Often

Always

I was aware of dryness of my mouth*

Never

Sometimes

Often

Always

I couldn't seem to experience any positive feeling at all*

Never

Sometimes

Often

Always

I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)*

Never

Sometimes

Often

Always

I found it difficult to work up the initiative to do things*

Never

Sometimes

Often

Always

I tended to over-react to situations*

Never

Sometimes

Often

Always

I experienced trembling (eg, in the hands)*

Never

Sometimes

Often

Always

I felt that I was using a lot of nervous energy*

Never

Sometimes

Often

Always

I was worried about situations in which I might panic and make a fool of myself*

Never

Sometimes

Often

Always

I felt that I had nothing to look forward to*

Never

Sometimes

Often

Always

I found myself getting agitated*

Never

Sometimes

Often

Always

I found it difficult to relax*

Never

Sometimes

Often

Always

I felt down-hearted and blue*

Never

Sometimes

Often

Always

I was intolerant of anything that kept from me getting on with what I was doing*

Never

Sometimes

Often

Always

I felt I was close to panic*

Never

Sometimes

Often

Always

I was unable to become enthusiastic about anything*

Never

Sometimes

Often

Always

I felt I wasn't worth much as a person*

Never

Sometimes

Often

Always

I felt that I was rather touchy*

Never

Sometimes

Often

Always

I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)*

Never

Sometimes

Often

Always

I felt scared without any good reason*

Never

Sometimes

Often

Always

I felt that life was meaningless*

Never

Sometimes

Often

Always

For each of the following questions, please choose the answer that best describes you.

Please rate the CURRENT SEVERITY of your insomnia problem(s).

Difficulty falling asleep*

None

Mild

Moderate

Severe

Very Severe

Difficulty staying asleep*

None

Mild

Moderate

Severe

Very Severe

Problems waking up too early*

None

Mild

Moderate

Severe

Very Severe

Carefully read each question below and answer to the best of your ability. Please note that some questions contain additional amplifying instructions.

How would you rate your AVERAGE pain level during the past week from 0 to 10?*

For the purposes of this question, consider 0 as being in no pain and 10 as being in the most extreme pain you've ever experienced.

How much total combined time each week do you engage in physical exercise?*

None

60 Minutes or less

61 to 90 minutes

91 to 120 minutes

More than 120 minutes

Please answer this question as it pertains to the LAST 4 WEEKS

To what extent do you think you are making sound financial decisions?

Almost never

Seldom

Occasionally

Often

Almost always

How healthy do you consider your eating habits to be?*

Very unhealthy

Somewhat unhealthy

Fairly healthy

Healthy

Extremely healthy

Please answer the following question as it pertains to the LAST 4 WEEKS

How much time do you engage in reading, listening to podcasts, or watching videos that help you understand how to live your life well (e.g. mental health and wellness, spiritual enlightenment, nutrition, exercise, personal finance)?*

None

1-2 hours per week

3-4 hours per week

5-7 hours per week

More than 7 hours per week

Please answer the following question as it pertains to the LAST 4 WEEKS

Please indicate the degree of happiness, all things considered, of your current relationship.*

Not currently in a relationship

Not at all

A little

Somewhat

Mostly

Almost Completely

Completely

In the questions to follow, you will be considering your most stressful or traumatic experience.

Please indicate what kind of experience this was:*

Combat Experience

First Responder Experience

Sexual Assault

Serious illness or death of a loved one (not combat related)

Relationship stress

Financial stress

Childhood abuse

Domestic violence

Legal problems

Natural disaster

Victim of crime

Serious or life-threatening illness

Indicate for each of the statements below the degree to which this change occurred in your life as a result or your most stressful or traumatic experience.

I changed my priorities about what is important in life.*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I have a greater appreciation for the value of my own life*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I developed new interests*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I have a greater feeling of self reliance*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I have a better understanding of spiritual matters*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I more clearly see that I can count on people in times of trouble*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I established a new path for my life*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I have a greater sense of closeness with others*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I am more willing to express my emotions*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I know better that I can handle difficulties*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I am able to do better things with my life*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I am better able to accept the way things work out*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I can better appreciate each day*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

New opportunities are available which wouldn't have been otherwise*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I have more compassion for others*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I put more effort into my relationships*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I am more likely to try to change things which need changing*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I have a stronger religious faith*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I discovered that I'm stronger than I thought I was*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I learned a great deal about how wonderful people are*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I better accept needing others*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I have a greater sense of harmony with the world*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I feel more connected with all of existence*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I feel better able to face questions about life and death*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

I have greater clarity about life's meaning*

I did not experience this change as a result of my stressful or traumatic experience

I experienced this change to a very small degree as a result of my stressful or traumatic experience

I experienced this change to a small degree as a result of my stressful or traumatic experience

I experienced this change to a moderate degree as a result of my stressful or traumatic experience

I experienced this change to a great degree as a result of my stressful or traumatic experience

I experienced this change to a very great degree as a result of my stressful or traumatic experience

To what degree have you felt that you have resolved the trauma(s) from your past?*

I have given up trying to resolve this as it does not seem possible for me

I have made some progress toward resolution

I have made a great deal of progress toward resolution

I feel almost completely, or completely resolved about these matters

Using the below description, please answer the following two questions to the best of your ability.

Imagine a ladder with steps numbered from zero at the bottom to 10 at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you.

On which step of the ladder would you say you personally feel you stand at this time?*

On which step do you think you will stand about five years from now?*

Thank you for taking the time to fill out this survey. Your honest answers help your fellow First Responders.