1.What is your age range?

18-24

25-34

35-44

45-54

55-64

2.Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

3.Where do you feel like you need the most support? (Select all that apply)

Emotional support

Physical health

Mental health

Parenting

Relationship support

Financial support

Feeling Heard

Other (please specify, where do you feel like you need the most support)

4.If you can do one thing for yourself, what would it be? (Select all that apply)

Take a break

Exercise

Seek therapy

Spend time with friends

Engage in a hobby

Meditate

Other (please specify, If you can do one thing for yourself what would it be?)

5.Have you been experiencing any changes in your mood or energy levels? If yes for how long?

Less than 1 year

1-3 years

3-5 years

More than 5 years

6.Is anything keeping you from seeking support? If yes, Select all that apply.

Job

Marriage

Children

Schooling

Financial Issues

Time

Other (please specify anything keeping you from seeking support)

7.What are some of the ways you are coping? (Select all that apply)

Talking to friends or family

Exercising

Meditation or mindfulness

Therapy or counseling

Medication

Other (please specify some of the ways you are coping)

8.Are there any specific life events or experiences that have affected your mental health? (Select all that apply)

Job

Children

Marriage

Family

Social life

Physical health

Financial Issues

Time (Issues with time management)

Other (please specify any specific life events or experiences that have affected your mental health)

9.Have you expressed this problem to anyone? If so, what solutions were explored?

10.How often do you practice wellness activities and what do you do?