Leaders of Tomorrow (LOT) Wellness Survey
Please take this survey to help us learn and serve the Black/African Ancestry/African community through no cost mental health access. Your responses will help us better understand community needs and inform our efforts in making mental health resources both relevant and accessible.
Where did you hear about this survey? (Please provide the specific title of the place you heard of this initiative i.e. Emmanuel Baptist Church San Jose, UC Berkeley, Loraine Bobbett (friend) etc.) *
First name *
Last name *
Age *
Ethnic/Racial Background *
Please detail your racial/ethnic background
Do you consent to the use of your anonymous response data to better understand and serve the Black/African Ancestry community's mental and communal wellness? *
What mental/emotional experiences have you personally experienced in 2020-2021? (Please mark all that apply.) *
Required
To what extent do you agree with this statement: I have found healthy and sustainable ways to care for my mental health in 2020-2021? *
To what extend do you agree with the statement: I am comfortable talking about my feelings with a mental health professional. *
To what extent do you agree with the statement: I am comfortable finding mental health services if or when I need to. *
To what extent do you agree with the statement: Mental health services are affordable and accessible. *
To what extent do you agree with the statement: I know where to go if I want to talk to a mental health professional. *
 Do you agree with the statement: Being connected to a mental health professional from my ethnic community would make me more comfortable seeking professional mental health support.
Clear selection
To what extent do you agree with the statement: Access to mental health resources is important to the well-being of the Black/African Ancestry/African community.
Clear selection
Do you agree with the following statement: There is a negative stigma surrounding mental health in the Black/African Ancestry/African community and Black/African Ancestry/African community church.
Clear selection
Do you agree with the following statement: I believe that the American Health Care system generally treats the Black/African Ancestry/African community with intention, understanding and care.
Clear selection
Do you agree with the following statement: The American Health Care system is largely disconnected from Black/African Ancestry/African communities and does not understand our mental health needs.
Clear selection
Do you agree with the following statement: As an Black/African Ancestry/African community member, I trust the American Health Care System to treat and care for my mental health.
Clear selection
What words/thoughts/images come to mind when you think of mental health as a Black/African Ancestry/African community member?
Have you ever wanted to see a mental health professional but decided not to because the cost was too expensive?
Clear selection
Please select the spaces where you feel most comfortable discussing your mental health?
 Send me more resources and opportunities to support mental health accessibility and wellness for the Black/African Ancestry/African community.
Clear selection
Any additional thoughts/questions?
Are you now or have you ever seen a licensed mental health professional? *
Would you like to participate in a 6 week small group to discuss your mental health and wellness? (Please leave best contact information below.)
Clear selection
What topics would be most helpful to discuss in small groups?
Email/Contact *
Any other thoughts/questions?
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