Community Listening Survey: Perinatal Mental Health

About You

WHO: People in Douglas and Josephine County, Oregon who are of reproductive age.

WHY: To provide your local health organizations with information to design programs to support families.

You can skip any questions that you do not want to answer. If you complete this anonymous survey, you will be eligible to enter a drawing to receive a gift card.

The first part of this survey will ask you about who you are.

Question Title

* 1. How old are you?

Under 18

18-24

25-34

35-40

41 +

Question Title

* 2. What is the highest level of education you have completed?

Did not graduate from high school or get a GED

Completed high school or GED

Some college or technical school

Graduated from college or technical school

Question Title

* 3. How do you describe yourself? (select one or more answers)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Native Hawaiian or other Pacific Islander

White or European American

Another race (please specify)

Question Title

* 4. What is your gender?

Agender

Female

Male

Nonbinary

Other (please specify)

Question Title

* 5. Do you identify as Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, or Asexual, etc.?

Yes

Not sure

Question Title

* 6. How many adults and children are living in your home right now? (Full or part-time)

Number of adults, including you

Number of children (under the age of 18)

Question Title

* 7. What is your zip code?

Question Title

* 8. How many live births have you had?

Currently Pregnant

4 or more

Question Title

* 9. Are you a...

Healthy Start Client

Community Resident Service Provider (not affiliated with the Perinatal Task Force)

Perinatal Task Force Member

None of the above