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CAC Community Needs Assessment
Horizons Mental Health Center's Child Advocacy Center (CAC) is conducting a community assessment on individual's living in the community and surrounding areas the CAC serves. All information obtained in this survey will be kept confidential.
1.
County of Residence
Barber
Harper
Kingman
Pratt
Reno
Out of State
Other Kansas County (please specify)
2.
Race/Ethnicity
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Multiple Races
Some other race
3.
What is the primary language spoken in the home?
English
Spanish
Other (please specify)
4.
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65+
5.
What is your sex assigned at birth?
Female
Male
Prefer not to answer
Not specified above, please specify
6.
What gender do you identify with?
Female
Male
Non-Binary or Genderqueer
Transgender female
Transgender male
I do not identify as any of these options
Unsure
Prefer not to answer
Prefer to self-describe as:
7.
What is your sexual orientation?
Asexual
Bisexual
Gay
Heterosexual or straight
Lesbian
Pansexual
Queer
None of the above, please specify
8.
What is your approximate average household income?
$0-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$124,999
$125,000-$149,999
$150,000-$174,999
$175,000-$199,999
$200,000 and up
9.
Do you identify with any of the following religions? (Please select all that apply.)
Protestantism
Catholicism
Christianity
Judaism
Islam
Buddhism
Hinduism
Native American
Inter/Non-denominational
No religion
Other (please specify)
10.
In general how would you rate the overall health your county
Unhealthy
Somewhat healthy
Healthy
Very healthy
11.
Are you aware of efforts in your community to prevent child abuse and maltreatment?
Yes
No
Unsure
12.
Has your child received school based child abuse prevention?
Yes
No
Unsure
Prefer not to answer
13.
In your opinion, is your household doing well? (ex: succeeding, thriving)
Yes
No
Unsure
14.
What is the primary mode of transportation for the household?
Own a car
Ride from family/friend
Walk
Bike
Public Transportation
15.
Is your household able to receive/get mental health and primary health care when needed?
Yes
No
Sometimes
16.
Does anyone in this household struggle with their mental health?
Yes
No
Unsure
No answer
17.
Do all members of the household feel safe in their...
Community
Household
Neighborhood
School
18.
Has anyone in your household been a victim of crime?
Adult sexual abuse
Child sexual abuse
Child witness violence in the home
Domestic violence
Human traficking
Internet
no one has bee a victim of any of these crimes
Physical abuse
Trauma exposure
Witness to violence
19.
In your opinion, what is the biggest concern of your community?
Abuse/Neglect
Addiction
Mental Health
Poverty
Other
20.
What other concerns/needs do you feel your community needs to address
