SW Washington Mental Health Needs Assessment Survey

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* 1. What is your age range?

Under 24

25-34

35-44

45-54

55-64

65-74

75 or older

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* 2. What is your race or ethnicity?

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Multiracial or Multiethnic

Native American or Alaska Native

Native Hawaiian or other Pacific Islander

White

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* 3. Gender: How do you identify?

Man

Non-binary

Woman

Prefer to self-describe, below

Self-describe:

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* 4. What is your primary language?

English

Spanish

Mandarin

Japanese

French

German

Italian

Russian

Hindi

Vietnamese

Other (please specify)

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* 5. Have you experienced any cultural barriers seeking healthcare in the past 12 months?

Yes

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* 6. How would you rate your current mental health?

Poor

Fair

Good

Very Good

Excellent

Poor

Fair

Good

Very Good

Excellent

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* 7. How would you rate your physical health?

Poor

Fair

Good

Very Good

Excellent

Poor

Fair

Good

Very Good

Excellent

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* 8. How would you rate your alcohol use?

I never use alcohol.

I use alcohol occasionally.

I use alcohol more than once a week.

I use alcohol on a daily basis.

I never use alcohol.

I use alcohol occasionally.

I use alcohol more than once a week.

I use alcohol on a daily basis.

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* 9. How would you rate your drug use? (Legal and illegal)

I never use drugs.

I use drugs occasionally.

I use drugs more than once a week.

I use drugs on a daily basis.

I never use drugs.

I use drugs occasionally.

I use drugs more than once a week.

I use drugs on a daily basis.

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* 10. In the last 12 months, have you experienced a loss of work or income?

No loss of work or income.

Minor loss of work or income.

Moderate loss of work or income.

Substantial loss of work or income.

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* 11. During the last 12 months, have you experienced problems getting medical care?

No problems getting medical care.

Minor problems getting medical care.

Moderate problems getting medical care.

Substantial problems getting medical care.

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* 12. During the last 12 months, have you been impacted by the lack of regular schooling?

No problems with schooling adjustments.

Minor problems with schooling adjustments.

Moderate problems with schooling adjustments.

Substantial problems with schooling adjustments.

Not applicable

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* 13. During the last 12 months, have you had issues getting childcare?

No problems getting childcare.

Minor problems getting childcare.

Moderate problems getting childcare.

Substantial problems getting childcare.

Not applicable

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* 14. During the last 12 months, have you been negatively impacted by travel restrictions?

No problems with travel restrictions.

Minor problems with travel restrictions.

Moderate problems with travel restrictions.

Substantial problems with travel restrictions.

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* 15. During the last 12 months, have you had problems with feeling isolated?

No problems feeling isolated.

Minor problems feeling isolated.

Moderate problems feeling isolated.

Substantial problems feeling isolated.

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* 16. During the last 12 months, has your housing been negatively affected?

No impact with housing.

Minor impact with housing.

Moderate impact with housing.

Substantial impact with housing.

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* 17. During the last 12 months, have you been negatively affected by public transportation shortcomings?

No impact on transportation.

Minor impact on transportation.

Moderate impact on transportation.

Substantial impact on transportation.

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* 18. During the last 12 months, have you been affected by domestic violence?

None

Once or twice

Monthly

Weekly

Daily

None

Once or twice

Monthly

Weekly

Daily

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* 19. Are you a veteran?

Yes

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* 20. If you are a veteran, have you received mental health services from the VA?

Yes

Not applicable

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* 21. If you use the VA, are you happy with their services?

Yes

Not applicable

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* 22. As a veteran, do you feel like your voice was being heard when seeking mental health services?

Yes

Not applicable

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* 23. As a veteran, do you feel like your case was important to your counselor?

Yes

Not applicable