Spirituality Initiative: Consumer/Client Survey 2016 Question Title * 1. Are you a: (Please select all that apply.) Client or consumer Family member Client/consumer and family member Question Title * 2. What is your age? Question Title * 3. What is your gender? Question Title * 4. What is your sexual orientation? Question Title * 5. What is your ethnicity/race? (Please select all that apply). African American/Black White/European American Chinese Hispanic/Latino(a) Filipino Guamanian Hmong Japanese Korean Middle Eastern/Arab Native American/Alaska Native Native Hawaiian Other Asian Ethnicity Other Pacific Islander Samoan Tongan Vietnamese More than one race/ethnicity Other...Please Specify Below Other (please specify) Question Title * 6. What is your primary language? Chinese English Farsi French German Japanese Korean Russian Spanish Tagalog Tongan Vietnamese Other...Please Specify Below Other (please specify) Question Title * 7. In which region do you receive services? Central County (San Mateo, Foster City, Belmont, Burlingame, Hillsborough) South County (San Carlos, Redwood City, Woodside, Atherton, West Menlo Park, Portola Valley) North County (Daly City, Pacifica, Colma, Brisbane, South San Francisco, San Bruno, Millbrae) East Palo Alto (East Palo Alto, East Menlo Park) Coastside (Half Moon Bay, Pescadero, La Honda) Other region within San Mateo Behavioral Health and Recovery Services. Please specify (Examples include: Therapeutic Day Schools, Youth Services Bureau, AOD treatment, Contract Agency, etc.) Question Title * 8. Do you distinguish between spirituality and religion? Yes No Unsure Question Title * 9. Do you identify with any of the following? (Please select all that apply). Agnostic Atheist Buddhism Christianity Earth based Hinduism Islam Judaism Native American Nothing Shamanism Spiritual but not religious Unitarian Universalist Other (please specify) Question Title * 10. Spirituality is important to me. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 11. Spirituality is an important aspect of wellness and recovery for me, and it should be incorporated in my mental health and/or substance use care. Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree Question Title * 12. The following spiritual practices have been helpful in my wellness and recovery. (Please select all that apply.) Attending a prayer vigil Attending a spiritual support group Attending religious services Centering exercises Chanting Dancing Drumming Journal writing Making crafts Meditation Participating in ritual ceremonies Participating in spiritual community social events Participating in sweat lodge (temazcal) Participating in talking circles Prayer Reading sacred texts or spiritual self-help books Receiving healing/advice from a medicine man or woman Reconciliation (making amends, forgiveness, upholding cultural beliefs/tradition) Singing Spending time in nature Volunteering in the community Yoga 12 steps group Other (please specify) Question Title * 13. Do you discuss spirituality with your... (Please select all that apply.) Case Manager Drug and Alcohol Counselor Family member Mental Health Counselor (MFT, LCSW, Psychologist) No one Peer (friend, colleague) Primary care provider/doctor Psychiatrist Religious/spiritual community Support group Question Title * 14. My mental health care and/or substance abuse providers have demonstrated respect for my spiritual beliefs. Agree Strongly agree Neither agree nor disagree Disagree Strongly disagree Spirituality has never been discussed with these providers. Question Title * 15. I would utilize spirituality as a wellness and recovery resource if offered by San Mateo County Behavioral Health and Recovery Services. Yes No Unsure Question Title * 16. Have you ever turned to a faith-based community or spiritual adviser (e.g., a minister, pastor, priest, rabbi, imam, shaman, elder, spiritual teacher, guru, spiritual healer, etc.) for mental health and/or substance abuse concerns? Yes No Question Title * 17. Do you practice your spirituality in a group setting (e.g. church, temple, synagogue, mosque, sangha, meditation center, etc.)? Yes No Sometimes Question Title * 18. If you answered "no" or "sometimes" above, would you like to practice your spirituality in a group setting? Yes No Question Title * 19. My involvement with a spiritual community has been helpful in working on my… (Please select all that apply.) Recovery Mental Health Substance use Medical needs Done