1. CRRBeliefSurvey-Individual (© 2012)

Center for Rapid Recovery (© 2012) Belief Survey for Individual

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* 1. YOUR NUMBER

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* 2. Last name

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* 3. First Name & Initial

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* 4. Date

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* 5. Gender

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* 6. Sexual Preference

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* 7. Race/Ethnicity

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* 8. Age Range

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* 9. Income Range

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* 10. Insurance?

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* 11. In your opinion how is the HIV Virus transmitted? ( Check all that apply)

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* 12. Do you believe HIV/AIDS is transmitted by: ( Check all that apply)?

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* 13. Do you believe that HIV/AIDS is a treatable disease?

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* 14. Do you believe that you can have unprotected sex with an HIV infected partner and not contract the virus?

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* 15. Do you believe that a person who is diagnosed with HIV/AIDS should tell their sex partner about their HIV/AIDS status?

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* 16. Do you believe that the HIV/AIDS virus was put in the minority community by the government?

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* 17. Do you believe the HIV/AIDS virus is a curse from God?

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* 18. Do you believe that the US government has a cure for HIV and is not sharing it with the public?

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* 19. Do you believe receiving treatment from someone of your racial/ethnic background can be more effective than services provided from someone other than your own background?

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* 20. Do you believe in God?

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* 21. Do you follow the dictates of your faith?

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* 22. Do you believe in divine healing?

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* 23. Do you believe that praying to God for help can improve your health?

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* 24. Presently, I believe my physcial condition ( check only one)

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* 25. Have you been given a diagnosis of mental illness by a medical professional?

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* 26. If, yes, do you agree with the diagnosis?

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* 27. What do you believe is the cause of Mental Illness? (Check all that apply)

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* 28. Do you feel that certain things can be done to make you feel better?

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* 29. Do you try different things on your own before seeking medical treatment?

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* 30. If yes, please Check all that apply

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* 31. Has a physician ever prescribed you medication that you didn’t take?

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* 32. If you answered No to the previous question tell us why (Check all that apply)

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* 33. Do you sometimes see or hear things that other people in the same room don’t see or hear?

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* 34. If yes, how do you cope with seeing things no one else does? (Check all that apply)

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* 35. Do you sometimes feel people treat you differently because of your race and ethnicity?

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* 36. Is it important to you that your health provider understands your relationship with God?

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* 37. Is it important to you that your health provider express a belief in God?

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* 38. Do you expect a health provider to take a personal interest like a friend when dealing with your medical problems?

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* 39. Do you believe that the world is inhabited by both good and evil spiritual being who can affect humans, particularly their health and well-being, in both positive and negative ways?

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* 40. Who do you turn to for help?

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* 41. Other than the use of drugs or alcohol, can something be used or done to make you feel better when you are down.

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* 42. If yes, what?

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* 43. Do you believe that a person can recover from using drugs?

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* 44. Do you believe that a person can think and do things better when they are high?

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* 45. Do you believe that drug use can affect a person’s health outcome?

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* 46. Do you believe that there is a relationship between the use of drugs and HIV/AIDS?

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* 47. Do you believe that counseling can help someone from using drugs or alcohol?

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* 48. Do you believe that a person can stop using drugs/alcohol on their own?

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* 49. Are you in need of recovery services?

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* 50. If yes, what do you believe you need to recover from?

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* 51. Are you familiar with the following term(s)? If yes, check all that apply.

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* 52. Do you believe that a disease/illness can stem from a (click all that apply)

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* 53. Have you ever received or consulted any of the following for help with the problem you seek help for today? (Check all that apply)

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* 54. Please indicate the intervention technique you believed can help you recover? (Check all that apply)

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* 55. Are you interested in integrating complimentatry therapies as part of your treatment plan?

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