Cultural stigma is a major barrier in accessing mental health care. Stigma surrounding mental illness can be more destructive than mental illness itself. This survey is aimed at identifying personal experiences with stigma relating to cultural values and beliefs which may impact one’s ability to utilize mental health resources. This survey is also seeking to identify sources of stigma which includes prejudice. Below is a brief definition describing cultural stigma.

Cultural Stigma: Culturally based shared attitudes and beliefs that negatively influences the way one thinks about the self, others, and society.

Please share in our concern, collaborating with us in moving toward a solution by participating in this cultural stigma survey. This confidential information will help us identify both the source and impact of cultural stigma to develop an appropriate advocacy plan and move toward social justice in our community.

The cultural domain includes, but is not limited to the following identifying information:

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* 1. Age:

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* 2. Gender:

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* 3. Sexual Orientation

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* 4. Spiritual/Religious Affiliations:

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* 5. Socio-economic status

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* 6. What is your Education level

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* 7. Ethnicity

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* 8. Do you Identify with more than one ethnicity?(If yes, Please list)

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* 9. Country of Citizenship

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* 10. Country of Birth

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* 11. Ability/Disability: How do you identify your functioning level?

  Extraordinary Ability Average Ability Disability
Mental
Physical
Other

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