Survey on Mental Health Services
** This is a confidential survey developed to track services related to the Cold Springs Fire. The intention is to help program managers better understand services, possible gaps in services, and will be used solely in the refinement of future services. Your help in answering these questions will greatly inform how we are able to address support in the future.
All information contained in this document is protected under HIPPA and will remain confidential.
What Gender do you identify with?
81 and older
What race or ethnicity do you identify with? (Please check all that apply)
Native American/Alaska Native
Native Hawaiian or Other Pacific Islander
What Boulder County community did you live in when the 2016 Cold Springs Fire occurred?
Town of Nederland
Did you access mental health services through any of the following areas:
Peak to Peak Counseling in Nederland
Nederland Community Presbyterian Church
Mental Health Partners/Housing and Human Services
If you did access services, were you made aware of the Mental Health Voucher program?
Yes, but did not use the program
Yes, and did use one $500 voucher
If you did access any of the above services, what symptoms led you to do so? (Please check all that apply)
Post-Traumatic Stress Disorder
Increased Irritability/Easily Frustrated
Inability to Complete Tasks
Increased Critical Thinking
If you did utilize the Mental Health Voucher Program, how did you learn about it?
Were there services you would have liked to receive, but didn’t? If so, what would they be?
Did you have physical, emotional or spiritual needs that weren’t met, and if so, how could they have been met?
Any other information you feel would be helpful for us to know?
May we contact you for an individual interview? If so, please provide your preferred means of contact.
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