ReFRESH Community Facilitator Questionnaire

ReFRESH is Reentry Finding Restoration & Establishing, Self-Healing. This program is created for Black justice-involved and/or formerly incarcerated individuals to bring training and mentoring to the community by the AMAAD Institute in partnership with the Department of Mental Health (DMH).

Community Facilitators (CFs) will serve as reentry experts to use their experience to support and develop others of lived experience with the goal to strengthen and support community while connecting to resources.

Your responses are confidential and protected and will only be used for anonymous data purposes.

Date * +

What meeting days would you prefer? *

Every third Thursday from 6:00 pm to 8:00 pm

Every third Friday from 6:00 pm to 8:00 pm

Every third Saturday from 11:00 am to 1:00 pm Every third Saturday from 11:00 am to 1:00 pm

Age *

Race/ Ethnicity that best describes you: (Please select one answer.) *

Black or African American

Latino or Hispanic

Asian or Pacific Islander

Native American or Alaskan Native

Multiracial or Biracial

White or Caucasian

A race/ethnicity not listed here A race/ethnicity not listed here

To which gender identity do you most identify? *

Sexual orientation (select all that apply) *

Are you formerly incarcerated? *

Yes

No

If yes, please select answer that best describes (select all that apply): *

How long ago did you serve? *

0-2 years ago

2-5 years ago

5-10 years ago

10+ years ago

How long did you serve? *

0-2 years

2-5 years

5-10 years

10+ years

Zip Code *

Phone number *

Email address *

What is your current employment status? *

Why are you interested in serving as a community facilitator for ReFRESH? *

Have you ever been a participant in a similar type of group? If so, please describe. *

Have you ever led in a similar type of group before? If so, please describe. *

Please select the most accurate response to the following question: "I am comfortable speaking in front of and leading groups of 6-20 people." *

I am comfortable working with diverse communities, including LGBTQ+ populations, women, youth, and people over 50? *

I am willing and able to host and support seven 2-hour session. *

I consider myself dependable. *

Others consider me dependable. *

I consider myself a people person. *

Others consider me a people person. *

I have experienced stigma or discrimination because of my employment status. *

Anything else you would like to share about yourself? *

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