Lived Experience Survey
A Survey To Assess the Impact of Trauma, Human Needs and Community Response on Mental/ Behavioral Health

This survey was developed to help you assess the impact of real life issues - like trauma, human needs, social relationships and community responses - on your personal well-being. No matter what difficulties you are having, there is a good chance that factors like these are affecting you in some way. Trauma, human needs and how those around us respond are closely related to both mental and behavioral health. Nobody feels or does well when their human needs are at risk, ignored or actually violated. Nobody feels or does well when those around them disregard, dismiss or actually blame them for the important concerns they are trying to raise.

That is the essence of the personal and social trauma that causes or worsens the mental and behavioral health challenges that so many of us face in modern society. All too often, however, the systems we turn to fail to connect the dots. If those we turn to for help don't make these connections, we may not either. Even worse, we may abandon the truth of our experience and our own knowing.

In this survey, we try to change that. We ask about many different kinds of experiences that can profoundly affect our sense of well-being. We also ask about many different areas of well-being - including mental, physical, social, educational, vocational and spiritual.

We are very interested in your responses. We are trying to understand the connection between real life issues and human well-being. We are also trying to raise awareness at state, national and international levels about these issues. Your honest responses can help us do that.

However, you have no obligation to submit this survey. You can just use it for your own awareness, if that is what feels right to you. (To print a copy for personal use, press the 'CTRL' and 'p' keys on your computer and follow the instructions for printing.) If you do choose to submit this survey, we will not disclose any identifying information you write out unless you give us express permission (see question #14).

Human Needs That We All Have
Here are some common human needs. These needs are so important that many nations around the world have concluded they are human 'rights'. With respect to your life, do all of these needs feel safe and secure? Have they always felt that way? (Check any that don't or didn't.)
Discrimination/ Bias/ Prejudice
All too often other people make things worse instead of better. They may highlight our vulnerabilities or even intentionally prey on them. They may judge or exclude us to advance their interests or agendas. Below are some ways this can happen. What kinds of marginalization have you experienced? (check all that apply)
Extent of social betrayal
The amount of harm we experience comes from more than just what happened. It also comes from how those around us respond (or fail to). Who actively participated? Who looked the other way? Who blamed instead of helped us? (check all that apply)
What harms or losses resulted?
When human needs are disrespected, violated or insecure, all sorts of harms can result. These are not illnesses. They are injuries. We should not be 'treated' as if we are the 'problem.' We deserve support to repair the damage and recover what we have lost. Properly speaking this should involve community support, validation, restitution and reparations, not medical providers 'diagnosing' and 'treating' us as if we are 'ill'. What harms or losses have you experienced? Check all that apply.
Duration of Injury/ Multiple Injuries
As a general rule, our injuries are more severe the longer we have suffered without meaningful redress. When did your injuries start? How many were there? How long have you been suffering?
Your answer
What was this like for you?
Please tell us, in your own words, anything else you would like us to know about how your life was impacted.
Your answer
What traditional mental health services have you tried (or been forced to try)?
Please check all that apply
What Other Things Have You Tried?
Please check all that apply
Learning From What Worked
What, if anything, did anyone (including you) do that was helpful? What seemed to make things better or stop them from getting worse?
Your answer
Constructive Criticism
What could/ should those responsible have done differently? What actions on their part could have prevented or lessened the harms to you?
Your answer
Big Picture Recommendations
How does society need to change to prevent the harms that happened to you? How can we change the way things operate in order to bring out the best in people instead of the worst?
Your answer
Other Comments/ Suggestions:
Is there anything we missed or could do better? Anything else you would like to add?
Your answer
What State or Nation are you from?
(This helps with advocacy and social change)
Your answer
How do you feel about us sharing your information for advocacy and social change purposes?
Contact Info (if you want us to try to reach you)
(Give preferred contact details here. E.g., name, phone, email, address, skype, facebook, google hangout, best days/ times)
Your answer
How to reach us:
Sarah Knutson, Organizer @ Peerly Human: Tel. 802-279-3876 Email:
Your answer
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