Community Survey
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1. Default Section

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1. Tribe or Ethnicity

Tribe or Ethnicity

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2. What city do you live in?

What city do you live in?

3. In which San Francisco neighborhood do you spend most of your time?

In which San Francisco neighborhood do you spend most of your time? Sunset Richmond Financial District Castro Hunter’s Point Tenderloin Mission Excelsior	Potrero Bayview Pacific Heights Noe Valley North Beach Bernal Heights Twin Peaks Hayes Valley	South of Market Visitation Valley Chinatown Western Addition Haight Downtown/Union Square
Other neighborhood (specify if not in San Francisco)

4. Where do you receive regular health services?

Where do you receive regular health services? Emergency rooms

Community clinics

Private medical offices

Other (please specify)

5. What is your gender?

What is your gender? Female

Male

Transgender

6. What is your age?

What is your age?

7. Which services/ activities would you participate in? (Select all that apply)

Which services/ activities would you participate in? (Select all that apply) Housing assistance Job training/placement Traditional Native activities Youth sports/recreation College and Career assistance Exercise Parenting education/groups Nutrition	Budgeting workshops Anger Management Youth academic tutoring Suicide prevention Smoking Cessation 12 Step groups Substance abuse treatment/counseling Domestic Violence prevention/support
Other (please specify)

8. Are you currently homeless?

Are you currently homeless? Yes

Not currently homeless, but I have been homeless in the past.

9. If homeless, did/do you receive services from any Community Organizations?

If homeless, did/do you receive services from any Community Organizations? Shelter

Mental Health

Food Assistance

Medical

Substance Abuse

Financial

No Services Received

Other (please specify)

10. Which of these issues affect the American Indian Community the most? (Check all that apply for Youth, Adults or Both)

	Youth	Adult	Both
Alcohol Abuse	*Which of these issues affect the American Indian Community the most? (Check all that apply for Youth, Adults or Both) Alcohol Abuse Youth	Alcohol Abuse Adult	Alcohol Abuse Both
Drug Abuse	Drug Abuse Youth	Drug Abuse Adult	Drug Abuse Both
Tobacco Use	Tobacco Use Youth	Tobacco Use Adult	Tobacco Use Both
Diabetes/Obesity	Diabetes/Obesity Youth	Diabetes/Obesity Adult	Diabetes/Obesity Both
Child Abuse/Neglect	Child Abuse/Neglect Youth	Child Abuse/Neglect Adult	Child Abuse/Neglect Both
Domestic Violence	Domestic Violence Youth	Domestic Violence Adult	Domestic Violence Both
Suicide	Suicide Youth	Suicide Adult	Suicide Both
Lack of Tribal Resources/Services	Lack of Tribal Resources/Services Youth	Lack of Tribal Resources/Services Adult	Lack of Tribal Resources/Services Both
Trauma	Trauma Youth	Trauma Adult	Trauma Both
HIV/AIDS	HIV/AIDS Youth	HIV/AIDS Adult	HIV/AIDS Both
Access to Health Care	Access to Health Care Youth	Access to Health Care Adult	Access to Health Care Both
Stress/Anxiety	Stress/Anxiety Youth	Stress/Anxiety Adult	Stress/Anxiety Both
Community Violence	Community Violence Youth	Community Violence Adult	Community Violence Both
Depression	Depression Youth	Depression Adult	Depression Both
Gambling	Gambling Youth	Gambling Adult	Gambling Both
Unplanned Pregnancy	Unplanned Pregnancy Youth	Unplanned Pregnancy Adult	Unplanned Pregnancy Both
Unemployment	Unemployment Youth	Unemployment Adult	Unemployment Both
Low Educational Attainment	Low Educational Attainment Youth	Low Educational Attainment Adult	Low Educational Attainment Both
Racism/Prejudice/Discrimination	Racism/Prejudice/Discrimination Youth	Racism/Prejudice/Discrimination Adult	Racism/Prejudice/Discrimination Both

Any additional comments for Friendship House?

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