Mental Health Survey #1 (2019-2020)
Program ID
Your answer
What zip code do you live in?
If you don't know your zip code, please specify what city and neighborhood you live in.
Your answer
Age Group
10-12
13-17
18-24
25-31
32-37
38-44
45-60
61 and above
Clear selection
Gender
Male
Female
Other:
Clear selection
What is your sexual orientation?
Heterosexual or Straight
Queer
Gay or Lesbian
Bisexual
Pansexual
Prefer not to answer
Other:
Do you consider yourself to be transgender or transsexual?
Yes
No
Prefer not to answer
Clear selection
Are you Hispanic or Latino/a
Yes
No
Other:
Clear selection
What is your race? (Check all that apply)
American Indian or Alaskan Native
Asian or Asian American
Black or African American
Native Hawaiian or other Pacific Islander
White
Prefer not to answer
Other:
What is the main language you speak at home?
Your answer
What is the highest level of education you have completed? (Please check only one)
Did not attend high school
Some high school, but did not graduate
High school graduate or GED
Technical or vocational training
Some college but no degree
Two year degree (i.e., Associate Degree)
Bachelor’s Degree
Master’s Degree or above
Other:
Clear selection
Do you currently have health insurance?
Yes
No
Don’t know
Clear selection
Are you currently working? (Please check only one)
No
No, I am in school
No, I am retired
No, I am unable to work
Yes, I work full time
Yes, I work part time
Clear selection
In the past year, how often did you worry about having enough money to pay for food or housing?
Always
Sometimes
Rarely
Never
Prefer not to answer
Clear selection
In the past year, which of the following health concerns did you face? (You may check more than one)
Arthritis
Asthma
Cancer
Chronic pain
Diabetes
Drug or alcohol abuse
Heart disease
Mobility impairment
Depression or anxiety
Other mental health challenge
Have you ever received services from a doctor and/or mental health professional for depression, or anxiety?
Yes
No
Prefer not to answer
Clear selection
Have you ever been hospitalized because of a mental health issue?
Yes
No
Prefer not to answer
Clear selection
Has anyone close to you (e.g., a parent, sibling, spouse, etc.) ever suffered from depression, anxiety, or mental illness of any kind?
Yes
No
Prefer not to answer
Clear selection
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