Improving Mental Health Outcomes: Stigma and Discrimination Survey

Transcription

1 Improving Mental Health Outcomes: Stigma and Discrimination Survey 1. Are you responding to this survey for: (Select one) Self Child Youth Spouse/Partner Friend Other: 2. Are you or the individual you are responding for receiving mental health services?, I/they are receiving mental health services now, I/they have never received mental health services I/they used to mental health receive services, but are no longer 3. What is your zip code? 4. What age group do you represent? If you are reporting for another person or child, please use their age): How do you identify your race and ethnicity? Please check all that apply. African American/Black/Person of African Descent Asian/Asian American White/European American Latino/Hispanic/Chicano Middle Eastern Native American/American Indian/Alaska Native

2 What Tribe? Native Hawaiian or other Pacific Islander What country, territory, or ethnicity? Other - Please describe: race and ethnicity. 6. How do you identify your gender? (Check all that apply) Male Female Intersex Transgender Transsexual Transman Transwoman Two spirit gender identity: 7. How do you identify your sexual orientation? (Check all that apply) Lesbian Gay Bisexual Pansexual Queer Questioning Straight/heterosexual Two spirit sexual orientation. 8. Would you consider yourself or your family immigrants or refugees? Immigrants move on their own volition because they want to relocate. They relocate for the promise of better economic condition, education, or family reasons. Refugees usually cannot return to their own country. They move out of fear or necessity. They are forced to relocate for reason such as fear of persecution due to war, religion, or political opinion, or because their homes have been destroyed in a natural disaster. Immigrants yes no not sure Refugees yes no not sure If so, approximately how many years have you or your family been living in the United States? Page 2 of 5

3 9. Are you fluent in a language other than English? If yes, which language(s)? 10. Do you or the person you are responding for have a mental health diagnosis/challenges? 11. If you or the person you are responding for has a mental health diagnosis/challenges, please indicate below: (Check all that apply) Depression Bipolar disorder Anxiety disorder ADHD Schizophrenia Post-Traumatic Stress Disorder 12. Have you ever heard of mental health stigma or discrimination based upon a mental illness of emotional/behavioral disorder/challenges? 13. Have you ever experienced stigma or discrimination related to mental, emotional, behavior disorders/challenges? 14. What was the setting for this experience(s)? (Check all that apply) Home Work School Church or other spiritual program Hospital Medical office or mental health provider Social Military Service 15. Did this experience interfere with your ability to: (Check all that apply) Live at home Get or keep a job Get an education with peers Worship in the manner you choose Have friendships and social opportunities Maintain a Military placement Get a job or Military promotion Receive treatment Page 3 of 5

4 16. Did you attempt to address or resolve the stigma or discrimination issues? 17. If you attempted resolution, were you successful? 18. Who assisted you in resolving the issues? (Circle all that apply) one Family Friend Co-workers School administrator Teacher Provider of mental health services (specify) Other professional (specify); Military Officer Work Supervisor Advocate from a peer or family run organization or program A mental stigma initiative or program 19. Have you or has your child or youth ever been called a name because of a mental, emotional, or behavioral disorder/challenge? 20. Do you and or does your child have other health care issues besides a mental, emotional, or behavioral disorder/challenges? 21. Do you have access to necessary mental health services? 22. If not, what services are you unable to access? (Check all that apply) Psychologist Psychiatrist Social worker Case manager Respite care Inpatient care Counseling Therapy Medication Page 4 of 5

5 23. What mental health stigma and discrimination reduction programs or activities are available in your community? For example: Programs that educate others about the bad effects of stigma and discrimination Programs or activities that are supposed to help communities understand mental illness/challenges Advertising about mental health stigma or discrimination Advocates for children, youth, and adults who have experiences mental health stigma and discrimination Other (Please describe): 24. Do you know of a legal advocate or support network in your county to help you if you felt that you were denied the opportunity to rent an apartment or get a job solely due to discrimination toward you or your family member's mental health-related behaviors/challenges? 25. Does your or your child's school or other community centers provide equal access for participation in all sponsored activities? 26. Have you or your dependent family member ever been told that because of their mental healthrelated behaviors/challenges, they must exclude them from participating in regular activities? 27. Please feel free to share anything else, including an experience you have had regarding mental health stigma and discrimination: Page 5 of 5