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?
Age
What race or ethnicity do you identify with? (Please check all that apply)
What Boulder County community did you live in when the 2016 Cold Springs Fire occurred?
Did you access mental health services through any of the following areas:
If you did access services, were you made aware of the Mental Health Voucher program?
If you did access any of the above services, what symptoms led you to do so? (Please check all that apply)
If you did utilize the Mental Health Voucher Program, how did you learn about it?
Your answer
Were there services you would have liked to receive, but didn’t? If so, what would they be?
Your answer
Did you have physical, emotional or spiritual needs that weren’t met, and if so, how could they have been met?
Your answer
Any other information you feel would be helpful for us to know?
Your answer
May we contact you for an individual interview? If so, please provide your preferred means of contact.
Your answer
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