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1
How would you rate your current mental health?
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Excellent
Good
Fair
Poor
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2
Have you or someone you know experienced any of the following in the past year? (Check all that apply)
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Anxiety
Depression
Stress-Related Issues
Substance Abuse
Suicidal Thoughts
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3
Do you feel there are enough local resources to support mental health and addiction recovery?
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Pick One
YES
NO
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4
If you or someone you know needed help, would you know where to go?
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Pick One
YES
NO
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5
What barriers make it difficult to seek help? (Check all that apply)
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Stigma or fear of judgment
Cost of services
Lack of transportation
Lack of awareness of resources
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6
What kind of support would you find most helpful? (Check all that apply)
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Counseling services
Addiction recovery programs
Support groups
Educational workshops on mental health/addiction
Prayer and spiritual support
Peer Support/Mentoring
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7
Are you interested in participating in or learning more about any of these programs?
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YES
NO
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8
Name
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First Name
Last Name
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9
Email
example@example.com
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10
Phone Number
Please enter a valid phone number.
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11
May we contact you?
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YES
NO
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