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The Umoh Foundation Questionnaire
This survey is 100% confidential and will be used to learn more about mental health in your community. Thank you.
* Indicates required question
Age
*
17- Under
18-29
30-42
43-65
65-older
Hometown (City and State)
Your answer
Are you of Hispanic/Latino/Spanish origin
Yes
No
Clear selection
How would you best describe yourself
African American
Caucasian
Asian or Pacific Islander
Other
American Indian or Alaska Native
Household Income
25,000 and under
26,000- 45,000
46,000- 59,000
60,000 above
Clear selection
Do you know anyone that went to therapy?
*
1 point
Yes
No
Have you ever been to therapy before?
*
1 point
No
Yes
Have you ever considered going to therapy?
*
Yes
No
Explain why you made your therapy decision
Your answer
What do you think is discussed during therapy?
*
Your answer
Have you ever been stressed?
Yes
No
Clear selection
How often are you stressed?
Daily
Every other day
Weekly
Every other week
Monthly
Clear selection
What is the source of your stress
Covid-19
Finances
Personal Relationships
Education
Family
Uncertain
Other:
Do you have goals?
Yes
No
Clear selection
How often do you set goals
Daily
Weekly
Monthly
Yearly
Other:
Clear selection
How often do you reach your goals?
More than half of the goals I reach
Less than half of the goals I reach
Clear selection
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