Community Survey

Nià:wen, thank you, for taking the time to complete this survey. This short survey has 9 multiple-choice questions and should take only a few minutes to complete.

Confidentiality Notice: Your responses to this survey are completely confidential. We will not share your individual responses or personal details with any third parties. By proceeding, you consent to the secure use of your confidential responses.

About you

3.If you live in Brockville, Perth, Lennox & Addington County. Please answer this question. For all others, please skip this question. When is the best time to start providing services in your area?

2026 (we need services now)

2027 (we need services soon)

2028 and beyond (we need services, but can continue to access them in other regions while we wait)

4.What is the main type of service you currently access?

Other (please state)

Your Health

5.Please rate your current physical health.

Excellent

Good

Poor

Prefer not to say

6.Please rate your current emotional health.

Excellent

Good

Poor

Prefer not to say

7.What is the biggest health issue that you face?

Other (please state)

8.What do you rely on the most to be healthy?

Being on the land

Connecting to traditional/cultural practices.

Eating well and being active

Using prescription medication

Using mental wellness supports (i.e. counselling, addictions recovery, therapy etc.)

Having relationships with my family and friends.

Having relationships with my healthcare provider(s) (i.e. nurse, youth worker, therapist etc.)

Other (please state)

Services

10.If you’d like your name to be entered into a draw for an Apple Watch or $200 grocery gift card, please provide your contact information.

First Name

Last Name

Email address

Phone number