Needs Assesment

This form is created to gauge awareness, accessibility to services, needs, and gather ideas and data. All questions are optional and anonymous, but we encourage you to fill out the form with as much information as possible as it will help us determine where the greatest needs are, as well as provide us with data that can be used to apply for grants and funding. Thank you so much for your time in helping the Silver Valley!

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Age

City of Residence

Gender

Profession

Have you experienced any of the following in the past?

Depression
Anxiety
Postpartum Depression
Suicidal Ideation
Suicide Attempt
Eating Disorder
Body Dysmorphia
ADHD
Bipolar Disorder
PTSD
Substance Abuse
OCD
Schizophrenia
Personality Disorder
Grief/Loss
Other

Other Diagnosis

Are you currently experiencing any of the following?

Depression
Anxiety
Postpartum Depression
Suicidal Ideation
Suicide Attempt
Eating Disorder
Body Dysmorphia
ADHD
Bipolar Disorder
PTSD
Substance Abuse
OCD
Schizophrenia
Personality Disorder
Grief/Loss
Other

Currently Experiencing

Do you have access to mental health services at this time? (Either locally or online)

If digital counseling were available, would you use this service?

If you have received mental health services in the past 5 years, please rank the quality of the services you received.

1 (worst)
2
3
4
5
6
7
8
9
10 (best)

Would you like to share any detail about your experince with mental health services?

What do you see as contributing factors to mental health challenges in our community?

What are some barriers you perceive or have experienced to accessing mental health services?

Are there any resources are available to you that you have found helpful? If so, please share what resources and how they were helpful

What services would you like to see in the Valley that you think would have the biggest impact?

Additional ideas/Other:

Feel Free to Reach Out!

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Name *

First

Last

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Email *

Phone

Comment or Message

Silver Valley Cares is comprised of community advocates, not mental health professionals, and offers support and advocacy for mental health issues within our community. Our guidance is not a substitute for professional mental health care, and we recommend consulting with qualified experts for personalized assistance.