Women’s Recovery Network Outreach Survey
Write a description of your survey here. Select any question below to change it. Then add questions as needed.
1.
What is your current age?
18-29
30-39
40-49
50-59
60+
2.
What is your ethnicity?
White
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Other (please specify)
3.
What is your drug of choice?
Alcohol
Opiates (Heroin, Fentanyl, Oxycodone)
Benzodiazepines (Ativan, Valium, Xanax)
Stimulants (Cocaine, Methamphetamines, Adderall)
Marijuana
Other (please specify)
4.
At what facility did you last receive treatment?
Gosnold Behavioral Health
Recovering Champions
Foundations Group Recovery Center
Duffy Health Center
I have never been to an inpatient treatment center
Relief recovery
Haven
Other (please specify)
5.
Are you currently in a 12 step program (AA/NA)?
Yes
No
6.
In what area of Cape Cod do you reside?
Upper Cape (Bourne, Falmouth, Mashpee, Sandwich)
Mid Cape (Barnstable, Brewster, Dennis, Harwich, Hyannis, Yarmouth)
Lower Cape (Chatham, Eastham, Orleans, Provincetown, Wellfleet)
Other (please specify)
7.
What is your current housing situation?
Sober Living
Year Round Rental
Seasonal Rental
Own Home
Live with family or friends
Homeless
Other (please specify)
8.
What is your current employment situation?
Part time
Full time
Part time (seasonal)
Full time (seasonal)
Unemployed/looking for work
Unemployed/ disability
9.
Is transportation an issue for you receiving help?
Yes
No
10.
What type of insurance do you have?
Federal
Medicare/Medicaid
Private insurance
I don’t know
I don’t have insurance
11.
Do you have a Primary Care Physician on Cape Cod?
Yes
No
No, but looking for a PCP
12.
Do you have a mental or behavioral therapist on Cape Cod?
Yes
No
No, but looking to establish with a therapist
13.
If you answered “yes” to Question 12, how often do you see your therapist?
Weekly
Bi-Weekly
Monthly
I don’t have a therapist
Other (please specify)
14.
Do you suffer from any of the following mental health issues? (Check all that apply)
Anxiety
Depression
PTSD
Bipolar Disorder
Social Isolation
Eating Disorders
Suicidal thoughts or behaviors
None of the above
15.
Have you experienced sexual assault or related trauma?
Yes
No
16.
Have you experienced physical or emotional abuse?
Yes
No
17.
Has RWW holistic healing practices(acupuncture, meditation, yoga, breath work etc) worked to support your physical and mental health?
Yes
No
No, but interested in accessing information and resources about these practices through an all women’s recovery network
18.
Which areas would you like to have more assistance with? (Check all that apply)
Employment
Housing
Child Care
Legal Issues
DCF, custody issues, or child support assistance
Continuing Education
Establishing Healthcare
Trauma Related Therapy
Other (please specify)
19.
Do you need financial assistance in receiving therapy?
Yes
No
20.
Would you like to learn about investing money for the future?
Yes
No
21.
Are you receiving services from the following ? (check all that apply)
Recovery Without Walls
Wellstrong
Falmouth Service Center
Falmouth Recovery Center
The Pause
Duffy Health Center
Pier Recovery Hyannis
Shamballa
The Baby Center
First Steps Together
