DMHA Cultural Competency Enhancement Project
Community Service Assessment for Faith-based Organizations

Goals of Assessment

The Division of Mental Health & Addiction is interested in surveying faith-based organizations to better understand:

1. what services are provided by faith-based organizations to the community today

2. how are these services funded at faith-based organizations

Your responses will help DMHA assess how supportive services are provided to Indiana communities.

Question Title

* 1. Your Information.
As the respondent you are answering the following assessment from your perspective assessing your faith-based organization.

First name

Last name

Your Role or Title at the Faith-Based Organization. If you do not hold an official role, please type in "congregation member".

Your Email address

Your Phone number

Question Title

* 2. I am willing to be contacted for further discussion:

Yes

If yes, please confirm preferred contact method (email, phone, or both).

Question Title

* 3. Your Faith-Based Organization's Information

Name of Faith-Based Organization

Address

City

Zip Code

County

Website

Question Title

* 4. Congregation Demographics.
Please fill in approximate representation from the following racial/ethnic minority groups in your congregation.

	Majority (over 50%)	Many (20-30%)	Few (less than 5%)	None
American Indian	American Indian Majority (over 50%)	American Indian Many (20-30%)	American Indian Few (less than 5%)	American Indian None
Asian	Asian Majority (over 50%)	Asian Many (20-30%)	Asian Few (less than 5%)	Asian None
Black or African-American	Black or African-American Majority (over 50%)	Black or African-American Many (20-30%)	Black or African-American Few (less than 5%)	Black or African-American None
Hispanic or Latino	Hispanic or Latino Majority (over 50%)	Hispanic or Latino Many (20-30%)	Hispanic or Latino Few (less than 5%)	Hispanic or Latino None
White	White Majority (over 50%)	White Many (20-30%)	White Few (less than 5%)	White None

Other (please specify)

Question Title

* 5. Gender Identity Demographics.
Please fill in approximate representation from the following gender identities in your congregation.

	Majority (over 50%)	Many (20-30%)	Few (less than 5%)	None
Female. Biological sex as female and self-identifies as female gender.	Female. Biological sex as female and self-identifies as female gender. Majority (over 50%)	Female. Biological sex as female and self-identifies as female gender. Many (20-30%)	Female. Biological sex as female and self-identifies as female gender. Few (less than 5%)	Female. Biological sex as female and self-identifies as female gender. None
Male. Biological sex as male and self-identifies as male gender.	Male. Biological sex as male and self-identifies as male gender. Majority (over 50%)	Male. Biological sex as male and self-identifies as male gender. Many (20-30%)	Male. Biological sex as male and self-identifies as male gender. Few (less than 5%)	Male. Biological sex as male and self-identifies as male gender. None
Gender non-conforming. Does not self-identify as male or female gender.	Gender non-conforming. Does not self-identify as male or female gender. Majority (over 50%)	Gender non-conforming. Does not self-identify as male or female gender. Many (20-30%)	Gender non-conforming. Does not self-identify as male or female gender. Few (less than 5%)	Gender non-conforming. Does not self-identify as male or female gender. None
Intersex. Biological sex does not fit definitions of female or male.	Intersex. Biological sex does not fit definitions of female or male. Majority (over 50%)	Intersex. Biological sex does not fit definitions of female or male. Many (20-30%)	Intersex. Biological sex does not fit definitions of female or male. Few (less than 5%)	Intersex. Biological sex does not fit definitions of female or male. None
Transgender. Self identifies gender identity.	Transgender. Self identifies gender identity. Majority (over 50%)	Transgender. Self identifies gender identity. Many (20-30%)	Transgender. Self identifies gender identity. Few (less than 5%)	Transgender. Self identifies gender identity. None

Other (please specify)

Question Title

* 6. Which services does your faith-based organization provide today?

Housing for those at risk of homelessness

Housing for re-entry individuals

Housing for youth

Housing for seniors

Food Pantry

Prepared Meals

Farm or gardens with access to fresh produce

Meal Delivery to Homes

Meal Delivery to Other Locations

Legal Advisory

Medical-Legal Partnership Access

Medical Ministry - Primary Care

Immunization & Vaccinations

Behavioral Health

Recovery Cafe

Transportation to doctor appointments

Transportation to grocery shopping

Transportation to run errands

Errand Running

Wellness Check in Homes

Wellness Check in Community

Prison Ministry

Re-entry Services

Gang Intervention

Grief Support

Domestic Violence Support

Marriage Counseling Support

Alcoholics Anonymous

Narcotics Anonymous

Tobacco Cessation Support

Gambling Addiction Support

Basic Needs - toiletries, clothing, food assistance, etc.

Infant Needs - formula, diapers, clothing, toys, etc.

Prescription Drop-off (unused medication collection)

Youth Groups

Motherhood Programs, Maternal Care Groups

Fatherhood Programs, Paternal Care Groups

Home School Support

Onsite Charter or Private School

Prevention Education Resources

Mental Health Education Resources

Addiction Education Resources

Counseling with licensed practitioner

What other pastoral care services does your faith-based organization provide?

Question Title

* 7. Does your faith-based organization offer services in any languages other than English today?

Yes

If yes, what other languages?

Question Title

* 8. What funding sources does your faith-based organization receive to support these services?
Please check all that apply.

Federal Funding Sources

State Funding Sources

Non-Profit Funding Sources

For-Profit Funding Sources

Congregation Tithing

Medicaid Reimbursement

Medicare Reimbursement

Other (please specify)

DMHA Cultural Competency Enhancement Project Community Service Assessment for Faith-based Organizations

Goals of Assessment

Question Title

* 1. Your Information. As the respondent you are answering the following assessment from your perspective assessing your faith-based organization.

Question Title

* 2. I am willing to be contacted for further discussion:

Question Title

* 3. Your Faith-Based Organization's Information

Question Title

* 4. Congregation Demographics. Please fill in approximate representation from the following racial/ethnic minority groups in your congregation.

Question Title

* 5. Gender Identity Demographics. Please fill in approximate representation from the following gender identities in your congregation.

Question Title

* 6. Which services does your faith-based organization provide today?

Question Title

* 7. Does your faith-based organization offer services in any languages other than English today?

Question Title

* 8. What funding sources does your faith-based organization receive to support these services? Please check all that apply.

DMHA Cultural Competency Enhancement Project
Community Service Assessment for Faith-based Organizations

* 1. Your Information.
As the respondent you are answering the following assessment from your perspective assessing your faith-based organization.

* 4. Congregation Demographics.
Please fill in approximate representation from the following racial/ethnic minority groups in your congregation.

* 5. Gender Identity Demographics.
Please fill in approximate representation from the following gender identities in your congregation.

* 8. What funding sources does your faith-based organization receive to support these services?
Please check all that apply.