Screen Reader Mode Icon
We want to know how you view our programs, so we are inviting you to participate in a survey for community health-needs. Your opinions are important. This questionnaire will take approximately 10 minutes to complete.
All of your individual responses are confidential. We will use results of the survey to improve our understanding of health needs in the community, as well as resourcing and prioritizing them accordingly to service you better.
Please read each question and mark the response that best represents your views of the community’s needs.

Question Title

* 1. What is you Zip code?

Question Title

* 2. what is you age group?

Question Title

* 3. What is you Gender?

Question Title

* 4. Please identify the Five (5) most important health issues in our community.

Question Title

* 5. Please Identify the  five (5) most important Unhealthy or Risky Behaviors in our community

Question Title

* 6. What do you think are the five (5) most critical Behavioral Health that concerns your community? (check only five)

Question Title

* 7. Please identify the five (5) most important factors that impact your well-being in our community.

Question Title

* 8. When you get sick, Where do you go?

Question Title

* 9. How long has it been since you have been to the doctor for a wellness exam /physical (not because you were already sick)?

Question Title

* 10. In the last year, was there a time when you needed medical care but were not able to get it?

Question Title

* 11. If you just answered "yes" to the previous question, why were you not able to get medical care? (choose all that apply)

0 of 38 answered
 

T