Silent Sons Needs Assessment
This survey is designed to assist men with evaluating the current state of their mental and emotional wellbeing so that we can tailor our programs and services to meet the needs of our clients and our Silent Sons Community.
About You
This demographic information helps us understand who our audience is so that we can target our information and content to best suite our community's needs.
How do you presently feel? (1. = I feel like giving up, 2. I'm struggling 3. I'm OK 4. I'm feeling good 5. My Life is great.
Bad
1
2
3
4
Great
5
1 is Bad, 5 is Great
What is your level of hopefulness for the future? (1. = Not hopeful, 2. It's out of my hands 3. Varies by the day 4. I think things will be fine 5 = Very hopeful)
None
1
2
3
4
Very
5
1 is None, 5 is Very
Race/Ethnicity
*
Please Select
African American/Black
Latino/Hispanic
Caucasian/White
Asian
Native American
Other or Mixed Race
Prefer Not to Disclose
Age
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55+
Relationship Status
*
Single
Committed Relationship
Married
Separated
Divorced
Co-habitating
Education Level
*
High School or Equivalent
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
Doctoral Degree
Employment Status
*
Employed Full Time
Employed Part Time
Self-Employed
Unemployed
Retired
Student
Income Range (Optional)
Less than $40,000
$40,000-$74,999
$75,000-$124,999
$125,000-$199,000
Over $200,000
Current State of Wellbeing
This is an opportunity to begin evaluating how you feel and what you need.
How often do you feel overwhelmed, angry, or emotionally shut down?
*
Please Select
Rarely
Occasionally
Frequently
Most of the Time
Every Day
If you have resisted seeking supportive services before? (Check all that apply)
Fear of judgement
Didn't know where to go
Didn't trust anyone
Didn't think it would help
Made me feel weak
Cost/Insurance
Not sure if I really need help
Concerned about my career/image/relationship if anyone found out
I should be able to handle it myself
Which of the following areas do you struggle with? (Check all that apply)
*
Anger
Irritability
Trust
Vulnerability
Confidence
Substance Abuse
Addiction (Non-Substance EX: Sex, Gambling, Pornography)
Fatherhood
Parenting/Co-Parenting
Relationship Management/Commuication
Self-Expression (Emotions/Thoughts/Needs/Feelings)
Sex/Intimacy
Isolation or Lonlieness
Self-Worth/Shame
Grief
Remorse/Regret
Legal or Court Issues
Identity/Masculinity
Past Trauma (Childhood, Relationship Violence)
Have you ever participated supportive or rehabilitative services before? (Check all that apply)
*
Therapy
Counseling
Group Counseling
Couples/Marital Counseling
Inpatient Treatment
Outpatient Treatment
Support Group
Peer Support Group (AA, NA)
Mentorship Program
Anger Management Classes
Parenting Classes
Other Court Ordered Programs
Other
Goals & Priorities
What is most important to you right now?
What are your top 3 goals for your healing or growth right now? (Check all that apply)
*
Learn to manage my emotions better
Learn to control my anger
Be a better father
Be a better partner
Improve relationnships with family & friends
Improve job performance
Improve my image (public or private)
Break destructive habits
Get clean/sober
Stay clean/sober
Rebuild my confidence
Repair broken relationships
Have someone to talk to who will really listen & understand me
Improve my communication skills / Learn how to express my feelings
Figure out what I really want
Restore my career
Feel like myself again
Have a safe space to learn how to deal with my past trauma
if you could change one thing in your life right now, what would it be? (Optional)
What do you wish someone understood about you/your experiences, as a man? (Optional)
Do you feel like you have the tools to 'fix' things on your own?
*
Yes
No
I don't know
Are you open to the idea of engaging in private advisory services?
Yes, please contact me
Yes, but not right now, just add me to your mailing list
Maybe, but I'd like to talk to someone to learn more
Not right now, but i'd like to be added to your mailing list
No
Submit
Should be Empty: