Assessing Mental Health Needs for our Community

This is a short survey that will help ensure the services needed are being supported.

Question Title

* 1. From the following list, what do you think are the three (3) most important issues in our community?

Depression

Grief/loss

Anxiety

Comping with chronic illness/physical health condition

Posttraumatic stress disorder

Alcohol use/abuse

Substance use/abuse

Domestic violence

Employment issues

Sexual trauma

Eating disorders

Caregiver stress

Bipolar disorder

Developmental disorder

Learning disorder

Suicide

Age-related issues

Child abuse and neglect

Current event stress

Question Title

* 2. What are the three (3) most important issues in your own life?

Depression

Grief/loss

Axiety

Coping with chronic illness/physical health condition

Posttraumatic stress disorder

Alcohol use/abuse

Substance use/abuse

Domestic violence

Employment issues

Sexual trauma

Eating disorders

Caregiver stress

Bipolar disorder

Developmental disorder

Learning disorder

Suicide

Age-related issues

Child abuse and neglect

Current event stress

Question Title

* 3. Have you ever been prescribed medication for a mental health diagnosis?

Yes

Question Title

* 4. Have you ever seen a mental health counselor or therapist for talk therapy?

Yes

Question Title

* 5. What is your age?

Under 18

18-24

25-34

35-44

45-54

55-64

65+

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* 6. What is your gender?

Female

Male

Transgender

I prefer not to answer

Other (please specify)

Question Title

* 7. What racial/ethnic group do you most identify with?

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Native Hawaiian or other Pacific Islander

White or Caucasian

Other (please specify)

Question Title

* 8. Which of the following best describes your current employment status?

Employed (full time)

Employed (part time)

Full time student

Part time student

Retired

Self-employed

Unemployed

Work two or more jobs

I prefer not to answer

Other (please specify)