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Coyote Valley Health Needs Assessment

1.Are you a Coyote Valley Tribal member (Required.)
2.Do you reside on the Reservation? (Required.)
3.What is your age range: (Required.)
4.Are you male or female (Required.)
5.Relationship Status:(Required.)
6.Children (under the age of 18): (Required.)
7.Ages of your children:
8.How often do you see your biological children?
9.If applicable, are you current on paying child support?
10.Are you owed child support?
11.What is your highest grade completed? (Required.)
12.What is your employment status?
13.Including yourself, how many adults reside in your home?(Required.)
14.How many youth reside in your home?
15.What is your approximate total household income range:
16.In the last five years, how often have you been incarcerated?
17.Are you currently on probation or parole?
18.In the last five years has the Tribe, a court or other program required that you attend:(Required.)
19.In the last five years, what is your experience with an inpatient recovery program?
20.Do you plan to start an inpatient or outpatient recovery program within the next year?
21.How many times in the last year, have you access behavioral health services (counseling, support groups, therapy, recovery services, etc.)
22.How many times in the last year have you wanted to access behavioral health services (counseling, support groups, therapy, recovery services, etc.) but chose not to or were unable to find what you needed?
23.Have you or a close relative experienced mental health complications or diagnoses?
24.How often do you or members of your household visit Consolidated Tribal Health (CTHP)?
25.In the last six months, please check how often:(Required.)
Never
Daily/Almost Daily
2-3 Days Per Week
Once Per Week
2-3 Days Per Month
A Few Times in Six Months
Did you drink alcohol?
Did you have 5 or more drinks on a single occasion?
Did you use marijuana?
Did you use methamphetamine?
Did you use whippits?
Did you use other drugs not listed above?
26.Thinking about the Coyote Valley members and community, how frequently have you or someone you know been impacted by the following types of crime:(Required.)
Weekly
Monthly
Once or Twice Per Year
Every Few Years
 Never
Adult Sexual Assault (i.e. rape, attempted rape, unwanted touching, forcing to perform sexual acts)
Child Sexual Abuse (i.e. exhibitionism, fondling, intercourse, obscene calls or messages, sharing pornographic images, sex of any type or sex trafficking)
 Assault physical injury- All ages; youth, teen or adult, elderly  
Domestic Violence/Intimate Partner Violence (a behavior to gain power and control over a spouse, partner, boyfriend/girlfriend or intimate family member and may include physical, sexual, emotional, verbal, economic or isolation)
Elder Abuse (i.e. the intentional act, or failure to act, by a caregiver that causes harm to an elder)
27.Thinking about the Coyote Valley members and community, how frequently have you or someone you know been impacted by the following types of crime:(Required.)
Weekly
Monthly
Once or Twice Per Year
Every Few Years
 Never
Fraud
Identity Theft
Gang Violence
Human Trafficking (i.e. recruitment, transportation, transfer, harboring, or receipt of persons by improper means (such as force, abduction, fraud, or coercion) for an improper purpose including forced labor or sexual exploitation.)
Robbery
Sexual Offense (not listed above)
Stalking
28.What services should the Coyote Valley Tribal Victim Services Program offer to victims?(Required.)
29.Select the level of agreement with each statement below:(Required.)
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
N/A
Our Community is Safe
I feel safe at home.
Our County Judicial System works well.
I am comfortable using our Tribal Court system.
I have confidence in the County Sheriff's Office.
If I witnessed a violent crime I would report it.
I would prefer Tribal Police handle calls for service (instead of the MCSO).
30.What are the 3 most important health challenges facing Coyote Valley Tribal Members?(Required.)
31.How do you prefer to receive newsletters and other communication?
Current Progress,
0 of 31 answered