Mental Health Survey

Section A

Please complete the following questions. These questions ask for some details about you in
order to help organize the information by sub-group for quality improvement purposes.

You may answer only the questions that you feel comfortable answering, and you may stop at any time.

Question Title

* 1. Please tell us what type of service you or your loved one are receiving from the list below:

Intensive Case Management

FLEX Support

Trauma Case Management

Dual Diagnosis

Streamlined Access

Community Crisis Beds

Question Title

* 2. What is your gender? (please check one box)

Question Title

* 3. Age (please check one box)

12 and under

13 - 18 years

19 - 25 years

26 - 34 years

35 - 44 years

45 - 54 years

55 - 64 years

65+ years

Question Title

* 4. What population group best describes you? (please check one box and then proceed to the more detailed question below that corresponds to your answer).