Veterans Needs Assessment Survey

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* 1. I am a:

Veteran

Spouse/Partner of a Veteran

Child of a Veteran

Caregiver of a Veteran

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* 2. My zip code is:

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* 3. My gender is:

Male

Female

Transgender Female/Feminine

Transgender Male/ Masculine

Genderqueer

Pangender

Other (please specify)

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* 4. My sexual orientation is:

Asexual

Bisexual

Gay

Heterosexual/Straight

Lesbian

Pansexual

Queer

Questioning

Other (please specify)

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* 5. My race/ethnicity is (check all that apply):

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic/Latinx

Native Hawaiian or other Pacific Islander

White or Caucasian

Biracial

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* 6. My age group is:

Under 18

18-27

28-44

45-59

60-84

85+

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* 7. My employment status is:

Employed

Retired - not disabled

Retired - disabled

Unemployed

Under-employed

Student

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* 8. My branch of service is/was:

Air Force

Army

Coast Guard

Marines

Navy

National Guard

Reserves

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* 9. My discharge status is:

Active duty military

Less than honorably discharged (does not affect accessing services)

Honorably discharged

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* 10. My discharge was due to a medical condition:

Yes

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* 11. I receive benefits through the Veterans Administration:

Yes

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* 12. I do or did receive benefits/services from another Veteran's assistance program:

Yes

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* 13. My healthcare is paid through (check all that apply):

Veteran's Administration

Private employer insurance

Marketplace insurance

Medicare

Medicaid

Federally Qualified Health Clinic (non-profit)

I do not have access to any resources for healthcare

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* 14. I have been treated for a mental health condition:

Yes

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* 15. I have been treated for a substance use disorder:

Yes

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* 16. I have a permanent place to live:

Yes

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* 17. I receive these services from the VA (check all that apply):

Primary care/medical

Dental

Vision

Hearing

Mental health counseling

Substance use disorder counseling

Case management

Food

Transportation - bus/rail/gas voucher

Transportation - van pick-up

Housing financial support

Employment services

Educational/Vocational training

Not applicable

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* 18. I need these services but have not been able to obtain them (check all that apply):

Primary care/medical

Dental

Vision

Hearing

Mental health counseling

Substance use disorder counseling

Case management

Food

Transportation - bus/rail/gas voucher

Transportation - van pick-up

Housing financial support

Employment services

Educational/Vocational training

Not applicable

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* 19. I am able to meet my financial obligations and living expenses:

Yes

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* 20. I am able to sustain a good quality of life:

Yes

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* 21. My most urgent unmet need is:

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* 22. I have encountered these barriers to receiving services (check all that apply):

Not aware of where to get services

Transportation difficulties

Discrimination

Not eligible

Wait lists

Confidentiality problems

Not applicable

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* 23. I feel that there is no one I can share my most private worries and fears with.

False

Probably false

Probably true

True

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* 24. There is someone I can turn to for advice about handling problems with my family.

False

Probably false

Probably true

True

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* 25. When I need suggestions on how to deal with a personal problem, I know someone I can turn to.

False

Probably false

Probably true

True

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* 26. If a family crisis arose, it would be difficult to find someone who could give me good advice about how to handle it.

False

Probably false

Probably true

True

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* 27. Lastly, if you would like someone to contact you about mental health services, please list your name, phone number and email.

Name:

Email Address:

Phone Number: