Please answer all questions relevant to your organization. Thank you for your participation. 

Brought to you by the Garland County Suicide Prevention Coalition, Community Service Incorporated, CHI St. Vincent, Project HOPE, Garland County Mental Health Court, The Difference Makers of Hot Springs, Accessible Legal Services, and Therapeutic Family Services.

Organization:

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* 1. Organization:

Organization Type:

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* 2. Organization Type:

If you had to choose a category for your group or organization to be listed in a directory, what would it be?

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* 3. If you had to choose a category for your group or organization to be listed in a directory, what would it be?

Name and position of person filling out the survey:

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* 4. Name and position of person filling out the survey:

Contact Number and Email: 

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* 5. Contact Number and Email: 

Website or Social Media where you can be found: 

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* 6. Website or Social Media where you can be found: 

Location:

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* 7. Location:

Hours of Operation:

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* 8. Hours of Operation:

Coverage Areas of Clients Served:

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* 9. Coverage Areas of Clients Served:

Ages Served:

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* 10. Ages Served:

Genders Served:

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* 11. Genders Served:

Special Populations Served:

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* 12. Special Populations Served:

What other groups or sub-populations does your organization support or advocate for?

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* 13. What other groups or sub-populations does your organization support or advocate for?

Spanish Speaking:

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* 14. Spanish Speaking:

Other Language Services

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* 15. Other Language Services

Does your organization collect demographic data on those you serve?

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* 16. Does your organization collect demographic data on those you serve?

Data Collection Method used, if any:

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* 17. Data Collection Method used, if any:

Services upon referral only:

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* 18. Services upon referral only:

Does your program require client pre-approval before they can be accepted?

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* 19. Does your program require client pre-approval before they can be accepted?

How often does your program open up to new clients? (i.e. every 6 weeks)

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* 20. How often does your program open up to new clients? (i.e. every 6 weeks)

Does your program have a waiting period? 

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* 21. Does your program have a waiting period? 

Name of Program(s) Used i.e. Anger Management (Please list all if more than one):

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* 22. Name of Program(s) Used i.e. Anger Management (Please list all if more than one):

Type of Program(s) Used: (Please indicate if more than one is used)

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* 23. Type of Program(s) Used: (Please indicate if more than one is used)

Additional services offered (Please describe):

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* 24. Additional services offered (Please describe):

Program Cost:

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* 25. Program Cost:

Payment Types Accepted (Please indicate all that apply):

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* 26. Payment Types Accepted (Please indicate all that apply):

What kind of funding does your organization have? i.e. Federal Grant etc

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* 27. What kind of funding does your organization have? i.e. Federal Grant etc

Average Number of Participants in Program:

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* 28. Average Number of Participants in Program:

Maximum capacity your program(s) can serve: (Please identify per program if more than one.)

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* 29. Maximum capacity your program(s) can serve: (Please identify per program if more than one.)

Current caseload per staff member:

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* 30. Current caseload per staff member:

How many people are part of your organization?

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* 31. How many people are part of your organization?

What is your staff to participant ratio?

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* 32. What is your staff to participant ratio?

Average number of people served annually.

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* 33. Average number of people served annually.

When is your peak period for your program?

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* 34. When is your peak period for your program?

Success or Graduation Rate: i.e. 65% or Half

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* 35. Success or Graduation Rate: i.e. 65% or Half

Incentives Offered:

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* 36. Incentives Offered:

Length of course or average length of completion time.

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* 37. Length of course or average length of completion time.

Dropout Rate:

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* 38. Dropout Rate:

What is the timeframe when participants might experience their highest chances of dropping out?

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* 39. What is the timeframe when participants might experience their highest chances of dropping out?

What are the most common reasons that might cause someone to dropout? 

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* 40. What are the most common reasons that might cause someone to dropout? 

Please list reasons for participant termination:

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* 41. Please list reasons for participant termination:

Sanctions used:

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* 42. Sanctions used:

Re-accept terminated participants?

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* 43. Re-accept terminated participants?

How do you make these services known to the public?

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* 44. How do you make these services known to the public?

Does your agency have a catalog of resources? i.e. a brochure, website, etc.

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* 45. Does your agency have a catalog of resources? i.e. a brochure, website, etc.

If yes, where can clients gain access to this?

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* 46. If yes, where can clients gain access to this?

Does your program require registration?

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* 47. Does your program require registration?

Does your organization host any community service programs? (i.e. Food Pantry, Grief Group etc)

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* 48. Does your organization host any community service programs? (i.e. Food Pantry, Grief Group etc)

What kinds of projects is your organization involved in now?

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* 49. What kinds of projects is your organization involved in now?

What has your organization accomplished thus far?

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* 50. What has your organization accomplished thus far?

Please describe your case flow:

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* 51. Please describe your case flow:

If your program refers out, to whom do you send your referrals? Please list in order of percentage referred from highest to lowest 5 being highest and 1 being lowest.

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* 52. If your program refers out, to whom do you send your referrals? Please list in order of percentage referred from highest to lowest 5 being highest and 1 being lowest.

Please list any community partners that your group works with on a regular basis:

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* 53. Please list any community partners that your group works with on a regular basis:

Can your clients become involved in a leadership type role in the program at any point?

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* 54. Can your clients become involved in a leadership type role in the program at any point?

If yes, please describe:

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* 55. If yes, please describe:

Does your program have any restrictions for clients? 

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* 56. Does your program have any restrictions for clients? 

If applicable, common drugs participants might be struggling with (Please rank from highest encountered to lowest 5 to 1):

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* 57. If applicable, common drugs participants might be struggling with (Please rank from highest encountered to lowest 5 to 1):

If applicable, common disorders participants might be struggling with (Please rank from highest encountered to lowest 5 to 1):

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* 58. If applicable, common disorders participants might be struggling with (Please rank from highest encountered to lowest 5 to 1):

Co-occurring disorders:

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* 59. Co-occurring disorders:

Do you use participant entrance and exit interviews?

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* 60. Do you use participant entrance and exit interviews?

If so, do you train your interviewers on proper interview procedures?

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* 61. If so, do you train your interviewers on proper interview procedures?

Does your organization have a grievance system? 

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* 62. Does your organization have a grievance system? 

How long do you keep these records on file? 

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* 63. How long do you keep these records on file? 

Does your organization have a praise system? 

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* 64. Does your organization have a praise system? 

How long do you keep these records on file? 

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* 65. How long do you keep these records on file? 

Assessment tool used, if any:

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* 66. Assessment tool used, if any:

How often does your organization do course evaluation/assessments/modifications? 

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* 67. How often does your organization do course evaluation/assessments/modifications? 

Do you use an outside evaluator? 

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* 68. Do you use an outside evaluator? 

If applicable, how long since last Evaluation was completed:

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* 69. If applicable, how long since last Evaluation was completed:

Methods of advertisement enlisted (Please rank from highest to lowest utilized 5 to 1):

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* 70. Methods of advertisement enlisted (Please rank from highest to lowest utilized 5 to 1):

Please specify the media organization utilized to reach the majority of your clients.

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* 71. Please specify the media organization utilized to reach the majority of your clients.

Do you train new staff? 

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* 72. Do you train new staff? 

Types of professional licenses that can be found within your organization:

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* 73. Types of professional licenses that can be found within your organization:

Are trainings ongoing?

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* 74. Are trainings ongoing?

Through whom are they offered?

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* 75. Through whom are they offered?

Types of trainings offered:

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* 76. Types of trainings offered:

Does your organization have a written policy or procedure manual? 

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* 77. Does your organization have a written policy or procedure manual? 

If yes, is your staff familiar with this policy or procedure manual?

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* 78. If yes, is your staff familiar with this policy or procedure manual?

Where does your organization meet?

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* 79. Where does your organization meet?

How often do you meet?

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* 80. How often do you meet?

Are your meetings open to the public?

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* 81. Are your meetings open to the public?

Do you gather outside of regular meetings? i.e. parties, gatherings etc. 

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* 82. Do you gather outside of regular meetings? i.e. parties, gatherings etc. 

What other spaces does your organization have access to?

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* 83. What other spaces does your organization have access to?

What kind of equipment does your organization have access to?

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* 84. What kind of equipment does your organization have access to?

What kind of written media materials/newsletters does your organization have?

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* 85. What kind of written media materials/newsletters does your organization have?

How does your organization keep its members up to date on activities and staff changes?

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* 86. How does your organization keep its members up to date on activities and staff changes?

Which of your organization's resources, if any, would you be willing to make accessible to other community members?

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* 87. Which of your organization's resources, if any, would you be willing to make accessible to other community members?

How many of your staff members live in the community served by your organization?

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* 88. How many of your staff members live in the community served by your organization?

Where do you purchase your supplies and equipment, go for repair services, etc.?

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* 89. Where do you purchase your supplies and equipment, go for repair services, etc.?

Does your organization host any community oriented events? (i.e. Alzheimer’s Walk)

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* 90. Does your organization host any community oriented events? (i.e. Alzheimer’s Walk)

Does your organization attend or assist (but not host) any community oriented events/programs/projects? Please list:

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* 91. Does your organization attend or assist (but not host) any community oriented events/programs/projects? Please list:

What are your organization's most valuable community oriented resources? (Tangible)

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* 92. What are your organization's most valuable community oriented resources? (Tangible)

In your opinion, what is your organizations strongest community oriented assets? (Intangible)

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* 93. In your opinion, what is your organizations strongest community oriented assets? (Intangible)

If you could add one thing to your program what would it be? i.e.: staff, training, services, etc

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* 94. If you could add one thing to your program what would it be? i.e.: staff, training, services, etc

What kind of new training programs would your organization be interested in taking on, directly related to your mission?

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* 95. What kind of new training programs would your organization be interested in taking on, directly related to your mission?

Any training or programs that might be indirectly related to, or outside of your mission?

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* 96. Any training or programs that might be indirectly related to, or outside of your mission?

What other projects or movements are you involved in that serve youth, the elderly, people with disabilities, the fine arts community, people receiving public assistance, immigrant or minority populations?

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* 97. What other projects or movements are you involved in that serve youth, the elderly, people with disabilities, the fine arts community, people receiving public assistance, immigrant or minority populations?

How feasible is it for your organization to get involved in more projects, more community development/health promotion efforts?

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* 98. How feasible is it for your organization to get involved in more projects, more community development/health promotion efforts?

What kind of changes would you like to see in the community in the next five years?

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* 99. What kind of changes would you like to see in the community in the next five years?

How would you help to effect these changes?

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* 100. How would you help to effect these changes?

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