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Name (Optional)

First Name

Last Name

Phone

(###)

###

####

Age Range

Under 18

18-25

25-34

45-54

55-64

65 and over

Gender

Male

Female

Other

Prefer not to say

Location

Urban

Surburban

Regional

Employment

Student

Employed part-time

Employed full-time

Not currently employed

Retired

Other

How often do you feel lonely?

Never

Rarely

Sometimes

Often

Always

How lonely did you feel yesterday?

Very lonely all day

Quite lonely some of the day

Neutral

A little lonely, some of the day

Not lonely at all

How often do you feel connected to the people around you?

Never

Rarely

Sometimes

Often

Always

How satisfied are you with your current social relationships?

Very satisfied

Somewhat satisfied

Neutral

Dissatisfied

Very dissatisfied

In the past week, how often have you interacted with friends or family in person?

Every day

Several times a week

Once a week

Rarely

Not at all

In the past week, how often have you interacted with friends or family online (e.g., social media, messaging apps, video calls)?

Every day

Several times a week

Once a week

Rarely

Not at all

How comfortable do you feel reaching out to friends or family when you are feeling lonely?

Very comfortable

Comfortable

Neutral

Uncomfortable

Very uncomfortable

Have you experienced increased feelings of loneliness since the COVID-19 pandemic began?

Yes, significantly

Yes, somewhat

No change

No, I feel less lonely

Not applicable

Which of the following activities do you participate in regularly? (Check all that apply)

Community groups (e.g., clubs, organizations)

Volunteering

Social events (e.g., parties, gatherings)

Hobbies or sports

Online communities or forums

None of the above