Community Needs Assessment
We are interested in learning about our community's most pressing needs and barriers. Your responses are anonymous unless you choose to share your identifying information with us. Thank you!
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What is today's date? *
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What is your age range?
Clear selection
What is your gender identity?
What is your cultural, ethic, and/or racial identity?
Are you a person with a disability?
Clear selection
What is your sexual orientation?
What religious tradition do you identify with, if any?
Where do you live (country and state/region/territory)? *
What are some of the biggest challenges you face in your life right now? For each category, check the box that fits your experience. Feel free to add your own as well:
0 Not a Problem
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10 Extremely Stressful
Financial
Employment
Housing
Parenting or Guardianship
General Stress
Relationships
Mental Health
Physical Health
Discrimination or Social Bias
Transportation
Child Care
Legal
Threat of Violence or Other Crimes
Cultural Identity Stress
Body Dissatisfaction
Feeling Isolated or Alone
Lack of Available Help
Caregiving for Adults
Other 1
Other 2
Other 3
Clear selection
Please describe any stressors labeled "Other ".
Do you have any interest in learning more about mindfulness and other contemplative practices for personal or collective health and well-being? *
Required
What are some barriers that might prevent you from learning about or practicing mindfulness? For each category, check the box that fits your experience. Feel free to add your own as well.
0 Not a Barrier
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10 Total Barrier
I don’t understand what mindfulness is.
I don’t understand what meditation is about.
I don’t understand how mindfulness can be beneficial to me.
I don't think mindfulness can help me with my problems.
I'm concerned mindfulness might conflict with my religious beliefs.
I'm concerned mindfulness might conflict with my cultural beliefs and/values.
I can’t find mindfulness teachers who look like me or who can relate to my life experience
Mindfulness isn't for people like me.
There's no convenient place for me to learn or practice mindfulness.
The people in my life would disapprove if I practiced mindfulness.
I don't have time to learn or practice mindfulness.
Learning & practicing mindfulness is too expensive for me.
Learning & practicing mindfulness is too difficult for me.
I'm just not interested.
Other 1
Other 2
Other 3
Clear selection
Please describe any barriers labeled "Other".
Are you a mindfulness teacher? *
Are you a member of the Midwest Alliance for Mindfulness (paying membership dues)? *
Would you like one of our teachers to contact you for further conversation about mindfulness? If so, please leave us your name, and email address and/or phone number here:
Thank you for your participation!
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