Self-Care Survey Demographic Information Question Title * 1. First/Last Name (Required.) Prefer not to answer Fill in below: Question Title * 2. Email: (Required.) Prefer not to answer Fill in below: Question Title * 3. With which gender identity do you identify with? (Required.) Cisgender Female (corresponds with birth sex) Cisgender Male (corresponds with birth sex) Transgender Female Transgender Male Gender Varient/Non-Conforming Prefer not to answer An option not listed (please specify below): Question Title * 4. Which race or ethnicity best describes you? (Please choose only one.) (Required.) American Indian or Alaskan Native Asian/Pacific Islander Black or African American Hispanic White/Caucasian Prefer not to answer Multiple Ethnicities/Other (please specify below): Question Title * 5. Sexual orientation (check all that apply): (Required.) Straight Lesbian Gay Bisexual/Bi-romantic Pansexual/Pan-romantic Asexual/A-romantic Queer Prefer not to answer Other (please specify below): Question Title * 6. What is your age range? (Required.) Under 25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66+ Prefer not to answer Question Title * 7. County: (Required.) Prefer not to answer Fill in below: Question Title * 8. What is your highest degree obtained? (Required.) High school diploma/GED Associate Bachelor's Master's Doctoral Question Title * 9. Level of social work practice (check all that apply): (Required.) Micro Mezzo Macro Student Retired Other (please specify below): Question Title * 10. How many years have you worked in the field (round to the nearest year)? (Required.) 2 years or less 3-5 years 6-10 years 11-15 years 16 years or more Question Title * 11. What social work license do you hold? (Required.) LBSW LSW LCSW I do not hold a social work license. Question Title * 12. What is your marital status? (Required.) Single Dating Married Widowed Divorced Separated Prefer not to answer Question Title * 13. What is your income range? (Required.) Less than $20,000 $20,000 to $30,000 $31,000 to $40,000 $41,000 to $50,000 $51,000 to $60,000 $61,000 to $70,000 $71,000 to $80,000 $81,000 to $90,000 $91,000 to $100,000 Above $100,000 Prefer not to answer Question Title * 14. Do you typically have free spending money? (Required.) Yes No Prefer not to answer Next
