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Transparency behind our procedures is important to us.

This is a partially survivor designed program: Many past participants in our program can answer “No” to several of the
questions asked and “Yes” to hospitalization questions when considering their past (including the
designer of this questionnaire and program alumni). Our concern is that you are well poised to be
able to show-up to training sessions. This program requires a twice-weekly commitment to a
one-hour training session. Consistency and the ability to show-up is key to succeeding in this
program. If you cannot show up consistently the program won’t work for you and it may be
better to defer your enrollment. Please answer the questions. Our client coordinator will contact
you to have a conversation about opportunities to enroll on MINE after completing this form.

M.I.N.E. Readiness Questionnaire

We want to ensure you are poised to get the most out of this program and are set-up
for success. Please take a few moments to answer this readiness questionnaire:

Are you in safe stable housing?
Are you out of an abusive relationship?
Do you consider yourself safe right now physically, emotionally, and psychologically in your living space?
Do you see a personal therapist?
Have you engaged in talk therapy with a licensed therapist in the past?
Is your doctor currently prescribing drugs for blood pressure or heart condition?
Have you had a psychiatric hospitalization in the past year?
Have you had a medical hospitalization in the past year?
Do you have active health insurance currently? (not needed for enrollment, the program is free of charge).

Thank you for submitting!

Please fill out the Health History Questionaire.

We Need Your Support Today!

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