Follow Up Questionnaire – Chasing Angels Fleeing Demons

Contact Information

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Demographics

Your Birthday *//

Gender *

Male
Female
Other

Race

American or Alaskan Native American
White/Caucasian
Black or African American
Other

Social Media Profiles

Instagram handle

Facebook Profile

Other Social Media Profiles

Mountain Motivations

What is your primary reason for visiting the mountains? *

Work
Recreation
Attention
Other

How often do you visit the mountains? *

Every week
Every month
Every three months
Every six months
Other

In what mountain range(s) do you spend most of your time? *

How old were you when you first visited the mountains? *

Who introduced you to the mountains? *

What is your relation to this person? *

How do you primarily enjoy the mountains? What activities do you participate in? *

Hiking, Climbing, Mtn Biking, Photography, Skiing, Etc.

Who do you typically go with? *

Alone
Friends
Family
Meet up groups
School or other organization
Guides
Pet
Other

What is your most memorable experience in the mountains? *

Please do not hold back. Details are important.

What is your worst experience in the mountains? *

Please do not hold back. Details are important.

What is it that you seek in the mountains? *

Shared experience with others
Escape
Physical Challenge
Other

Please explain what it is that you seek. *

What keeps you coming back to the mountains? *

What are your goals and ambitions? *

Dream destination, fitness goals, emotional goals, etc.

Do you believe that the mountains are therapeutic? *

Yes
No
Not sure

Personal Information

How would you describe the relationships in your life? *

Extremely healthy
Healthy
Unhealthy
Toxic

Marital Status *

Single
Married
Divorced
Separated
Widowed
Other

Do you have children? *

Yes
No
No Comment

Do they live with you?

Full-time
Part-time
No

How would you describe your childhood? *

Extremely healthy
Healthy
Unhealthy
Toxic

Have you ever been the victim of abuse? *

yes
No
No comment

What kind of abuse? *

Verbal
Physical
Sexual
Other

What is more motivating? Earning money, building relationships or personal happiness? *

Earning money
Building relationships
Personal happiness

Are you clinically diagnosed with any mental illness or conditions? *

Yes
No
No Comment

Will you share your diagnosis?

Are you clinically diagnosed with any physical illness or conditions? *

Yes
No
No Comment

What is your diagnosis?

Have you ever been a victim of bullying? *

Yes
No
No Comment

How old were you and who bullied you?

Have you ever been a victim of a hate crime? *

Yes
No
No Comment

Please explain.

Have you ever been convicted of a crime? *

Yes
No
No Comment

What kind of crime were you convicted for?

Felony
Felony-misdemeanor
Misdemeanor
Infraction

What crime were you convicted for?

Did you spend time in jail?

More than 5 years
Between 3-5 years
Between 1-3 years
Less than 1 year
Other

How old were you?

Have you ever been addicted to a substance? *

Yes
No
No Comment

What were you addicted to?

Opiod
Illegal Drug
Alcohol
Other

Are you sober now?

Yes
No
Other

How long have you been sober for?

More than 5 years
Between 3-5 years
Between 1-3 years
Less than 1 year
Other

Do you a member of any religious group? *

Yes
No
No Comment

What religious group are you a member of?

Christian
Islam
Hindu
Individual
Other

What religion do you associate with?

Does your religion influence they way you live?

Yes
No
No Comment

Anything else?

So, What is your answer? *

Please explain your choice. *

Before answering please consider: Your best experience in the mountains. Worst experience. Why do you typically go to the mountains? Who do you go with? What got you hooked? And why do you keep going back? Consider your life circumstances. The stresses and releases. Your childhood and future. Decisions you've made in the past that has influenced who and where you are today.

I have read the confidentiality and non-disclosure agreement *

I have read the confidentiality and non-disclosure agreement

Consent to Share *

First

Last

By entering your name and submitting this form, you allow us to contact you for matters pertaining to Chasing Angels or Fleeing Demons.