Spirituality Survey-Provider version

Question Title

1. Are you a... (Required.)

BHRS staff member

Community provider

Question Title

2. What is your age? (Required.)

18-25

26-36

37-47

48-57

57-70

70+

Question Title

3. Are you a... (Required.)

LCSW

MFT

LPCC

Psychologist

Psychiatrist

Administrative staff

Case manager (not licensed)

Other...Please Specify Below

Other (please specify)

Question Title

4. How do you identify your gender? (Required.)

Female

Male

Transgender

Gender non-conforming

Other...Please Specify Below

Other (please specify)

Question Title

5. How do you identify your sexual orientation? (Required.)

Gay/Lesbian

Straight

Bisexual

Asexual

Pansexual

Other...Please Specify Below

Other (please specify)

Question Title

6. How do you identify your ethnicity/race? (Required.)

African American/Black

American Native/Alaskan Native

Chinese

Filipino

Guamanian

Hispanic/Latino(a)

Hmong

Japanese

Korean

Middle Eastern/Arab

Native Hawaiian

Samoan

Tongan

Other Asian Ethnicity

Other Pacific Islander

Vietnamese

White/European

More than one race/ethnicity

Other...Please specify Below

Other (please specify)

Question Title

7. What is your primary language? (Required.)

English

Spanish

Chinese

Korean

Japanese

Vietnamese

Tagolog

Russian

Farsi

German

French

Other...Please Specify Below

Other (please specify)

Question Title

8. In which region do you provide services? (Required.)

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 County Behavioral Health and Recovery services: Examples include therapeutic day schools, youth services Bureau, AOD treatment, etc

Question Title

9. How long have you worked in this field? (Required.)

0-6 months

6 months-1 year

1-5 years

6-10 years

10-14 years

15 years+

Question Title

10. Do you identify with any of the following? Check the most important spiritual practice to you, and add another in the box if you identify with more than one. (Required.)

Agnostism

Atheism

Buddhism

Christianity

Earth based

Hinduism

Islam

Judaism

Native American spiritual tradition

Nothing

Shamanism

Unitarian Universalism

Other...Please Specify Below

Other (please specify)

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* 1. Are you a... (Required.)

Question Title

* 2. What is your age? (Required.)

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* 3. Are you a... (Required.)

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* 4. How do you identify your gender? (Required.)

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* 5. How do you identify your sexual orientation? (Required.)

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* 6. How do you identify your ethnicity/race? (Required.)

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* 7. What is your primary language? (Required.)

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* 8. In which region do you provide services? (Required.)

Question Title

* 9. How long have you worked in this field? (Required.)

Question Title

* 10. Do you identify with any of the following? Check the most important spiritual practice to you, and add another in the box if you identify with more than one. (Required.)

1. Are you a... (Required.)

2. What is your age? (Required.)

3. Are you a... (Required.)

4. How do you identify your gender? (Required.)

5. How do you identify your sexual orientation? (Required.)

6. How do you identify your ethnicity/race? (Required.)

7. What is your primary language? (Required.)

8. In which region do you provide services? (Required.)

9. How long have you worked in this field? (Required.)

10. Do you identify with any of the following? Check the most important spiritual practice to you, and add another in the box if you identify with more than one. (Required.)