Susanville Indian Rancheria
Community Assessment Survey

Susanville Indian Rancheria is a recipient of a federal grant – Circles of Care (C of C). C of C is a three (3) year planning grant to develop a community-based services for children with mental health challenges and to support their families in helping children grow in a good way. Children’s mental health challenges include depression, anxiety, suicidal thoughts, and substance use issues.

It would be greatly appreciated if you would complete this brief survey, which will help C of C leadership understand the challenges that children and their families face. Thanks!

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* 1. What is your age?

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* 2. What is your gender?

Male

Female

Prefer NOT to answer

If Other (please specify)

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* 3. Which of the following best describes you (check all that apply)?

African American/ Black

American Indian/ Alaska Native

Hispanic/ Latino

White

Multiracial

If Other (please specify)

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* 4. What is your current relationship status?

Married

Single

In a relationship

If Other (please specify)

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* 5. Do you currently care for children under 18 years of age?

Yes

No