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Have you taken part in an Empathy Circle?  Your feedback would help us 

Email address:  [      ]

Name: 
 [      ]

Name of Facilitator: [      ]

Topic:  [      ]

How would you classify yourself politically on economic issues?
Conservative ( )1 ( )2 ( )3 ( )4 ( )5  ( ) center ( )6 ( )7 ( )8 ( )9 ( )10   Progressive

How would you classify yourself politically on social issues?
Conservative ( )1 ( )2 ( )3 ( )4 ( )5  ( ) center ( )6 ( )7 ( )8 ( )9 ( )10   Progressive


I Like:
   [      ]

I Wish:   [      ]

What If:  [      ]


Would you take part again?  (  )Yes (  )No  (  )Maybe

Would you recommend an Empathy Circle to family/friends? (  )Yes (  )No 

Would you like to learn how to facilitate an Empathy Circle? (  )Yes (  )No 

What do you learn? [      ]

Other Comments:   [      ]


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