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Name of Prison
   
 
 
 
Name
   
 
 
 
Age
   
 
 
 
Ethnicity
 
Asian - British
 
Asian - Bangladeshi
 
Asian Indian
 
Asian - Other
 
Asian - Pakistani
 
Black - African
 
Black - British
 
Black - Caribbean
 
Black - Other
 
Chinese
 
Latin American
 
Middle Eastern
 
Mixed Ethnicity
 
Prefer not to say
 
White British
 
White European
 
White Irish
 
White—Other
 
 
 
Do you have any previous musical experience? If so what is it?
 
No
 
yes, please say:
 
 
 
Have you ever used music as a coping mechanism in the past? (please circle)
 
Yes
 
No
 
 
 
How do you feel music might help you in your recovery?
   
 
 
Rate the following (1= not at all, 6 = very)
1 2 3 4 5 6
How confident do you think you are?
How comfortable are you working in a group?
 
 
How far do you agree with the following statements? (1=strongly disagree, 6=strongly agree)
1 2 3 4 5 6
"I have hope for the future."
"I feel motivated to take part in other activities/groups in this prison."
 
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