SWX Initiation Survey

Program Number*

Please select your class number from the below options. If you are unsure of your class number, please check with your guide.

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 feeling bothered by that problem over the past 24-48 hours. 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

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?*

How likely is it that you would recommend SWX to a friend of colleague?

Select from 0-10 where 0 is "Not at all likely" and 10 is "Extremely likely"

Think about how attending SWX has impacted you. Describe the ways in which you have changed and grown as a result of your attendance.*

How has participation in the Struggle Well Experience program caused you to reconsider how you view your past experiences as well as how you now view your life going forward?*

What do you think your future would look like if you had never attended the Struggle Well Experience?*

What do you believe will be your most significant challenges going forward after you leave today?*

What support and resources do you believe would help you overcome these challenges?*

If you were asked by a friend, family member, or co-worker to describe your experiences during the Struggle Well Experience, what would you say?*

In what ways do you believe you will make the biggest positive impact on your family, community, and Country going forward? In other words, how will you make the world a better place?*

Is there anything you think we could or should do to improve the program or experience for future participants?*

Between applying for and attending the program, what information would have been helpful to maximize your ability to benefit from the Struggle Well Experience (this could be information about the Struggle Well Experience, regulation practices, stories from alumni, etc.)?*

Considering your answer to the previous question; what format would you have liked to receive that information (books, articles, audio clips, podcasts, videos, zoom calls, other)?*

In what ways can the Struggle Well Experience team further support your growth and recovery?*

Please provide any specific guidance, advice or feedback you'd like to give to the Struggle Well Experience staff about your experience.*

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

Please read each statement and indicate how much the statement applied to you over the past 24-48 hours. There are no right or wrong answers. Do not spend too much time on any statement.

For each of the following questions, please choose the answer that best describes you over the last 24-48 hours.

Carefully read each question below and answer about how you have felt over the past 24-48 hours. Please note that some questions contain additional amplifying instructions.

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

Indicate for each of the statements below the degree to which this change occurred over the past 5 days as a result or your most stressful or traumatic experience.

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