Mental Health Survey

Section A

Please complete the following questions. These questions ask for some details about you in
order to help organize the information by sub-group for quality improvement purposes.

You may answer only the questions that you feel comfortable answering, and you may stop at any time.

Question Title

1. Please tell us what type of service you or your loved one are receiving from the list below:

Intensive Case Management

FLEX Support

Trauma Case Management

Dual Diagnosis

Streamlined Access

Community Crisis Beds

Question Title

2. What is your gender? (please check one box)

Question Title

3. Age (please check one box)

12 and under

13 - 18 years

19 - 25 years

26 - 34 years

35 - 44 years

45 - 54 years

55 - 64 years

65+ years

Question Title

4. What population group best describes you? (please check one box and then proceed to the more detailed question below that corresponds to your answer).

Question Title

* 1. Please tell us what type of service you or your loved one are receiving from the list below:

Question Title

* 2. What is your gender? (please check one box)

Question Title

* 3. Age (please check one box)

Question Title

* 4. What population group best describes you? (please check one box and then proceed to the more detailed question below that corresponds to your answer).

1. Please tell us what type of service you or your loved one are receiving from the list below:

2. What is your gender? (please check one box)

3. Age (please check one box)

4. What population group best describes you? (please check one box and then proceed to the more detailed question below that corresponds to your answer).