Region 5 Recovery Hub Individual Needs Assessment Survey
1.
Are you currently in recovery?
Yes
No
2.
Please identify how many months you have been in recovery.
3.
Have you received recovery support services in the past year?
Yes
No
4.
Are you currently receiving recovery support services? (If yes, please describe below)
Yes
No
If you are currently receiving recover support services please describe them here:
5.
Are you currently seeking recovery support services? (If yes, please describe the services you are seeking.)
Yes
No
Please describe the services you are currently seeking.
6.
Did you face challenges when entering recovery? (If yes, please describe below.)
Yes (Please describe below)
No
Please describe challenges or barriers faced.
7.
Have you faced challenges staying in recovery? (If yes, please describe below)
Yes (Please describe below)
No
Please describe challenges or barriers faced.
8.
What types of recovery support services have you used? Select all that apply. If other please describe below.
Peer support
Educational workshops
Substance use counseling
Employment assistance
Housing assistance
Legal services
Other
Other (please specify)
9.
Please rate your agreement to the following statement: There are enough recovery support services available to me.
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
10.
Please rate your agreement to the following statement: Recovery support services are easily accessible for me.
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
11.
Please rate your agreement to the following statement:
There are a variety of support recovery services available to me
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
12.
Please rate your agreement to the following statement:
Access to recovery support services is equitable (e.g., everybody has fair and equal access).
Strongly Agree
Agree
Neither Agree nor Disagree
Disagree
Strongly Disagree
13.
Please rate the quality of the services available to you.
Very High
High
Neither High nor Low
Low
Very Low
14.
What has been the most helpful aspect of the recovery support services for you?
15.
In what areas do you think improvements are needed in the recovery support services? Select all that apply. If other please describe.
Availability of services
Quality of services
Access to information about services
Support for employment
Support for housing
Legal support
Other
Other (please specify)
16.
Do you feel that the recovery support services are culturally and linguistically appropriate?
Yes
No
Not sure
17.
What additional support or services would you find helpful in your recovery journey?
18.
Which county do/did you receive your recovery support services in?
Adams
Bedford
Blair
Cumberland
Dauphin
Franklin
Fulton
Huntingdon
Juniata
Lebanon
Mifflin
Perry
York
Other/Prefer not to say
19.
How do you identify?
Male
Female
Other (please specify)
20.
Are you a part of the LGBTQIA+ community?
Yes
No
21.
Which category below includes your age?
Under 18
18-24
25-34
35-44
45-54
55-64
65+
22.
Please indicate your race
American Indian
Asian or Asian American
Black or African American
Native Hawaiian or other Pacific Islander
White
Other (please specify)
23.
Are you of Hispanic or Latino/a origin?
Yes
No
24.
What is your marital status?
Single/Never Married
Married
In a domestic partnership
Seperated
Divorced
Widowed
Other (please specify)
25.
What is the highest level of school you have completed or the highest degree you have
received?
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
26.
Which of the following categories best describes your employment status?
Full-time (working 40 or more hours per week)
Part-time (working one to 39 hours per week)
Seasonal work
Not employed, looking for work
Not employed, NOT looking for work
Retired
Disabled, not able to work
Other (please specify)
27.
How much total combined money did all members of your household earn in 2022?
$0-$9,999
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,000
$50,000-$59,999
$60,000-$69,999
$70,000-$79,000
$80,000-$89,000
$90,000-$99,999
$100,000 or more
28.
Please share any other comments or suggestions you have about the recovery support services.
