My State of Mind Feedback Form

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Thank you for taking the time to view the guidebook!

A great part of My State of Mind is its technology which can be improved at any time. With your help we want to make My State of Mind the best it can be for you, your community, and the entire county.

On this form you will answer demographic questions about yourself before answering feedback questions regarding the platform. Please do not start this form without viewing the My State of Mind Guidebook!

We appreciate your honest feedback!

Email *

Which best describes your gender identity currently? *

CIS Man

CIS Woman

Trans Man

Trans Woman

Non-binary/Gender Non-Conforming

Prefer to self describe

Prefer not to say

Please select which group best describes your age group. *

Student (Ages 10-17)

Young Professional (Ages 18-24)

Professional (Ages 25 - 35)

Professional (Ages 36 - 64) Without Children

Professional (Ages 36 - 64) With Children

Silver Stars (Ages 65+)

Which best describes your race? (Check all that apply) *

Native American or Alaskan Native

Asian

Native Hawaiian or Other Pacific Islander

Black or African-American

White

Hispanic, Latino or Spanish of any race

Required

What is your ethnicity? (Optional)

What is your nationality? (What country were you born in?) *

Languages Spoken *

Which describes your current employment situation? *

Employed Full-Time

Employed Part-Time

Self-Employed

Retired

Multiple Places of Employment

Currently in school full-time

Home maker

Unemployed but looking for work

Unemployed/Currently unable to work for health/disability reasons

Which best describes your current occupation / career? *

Education (Teacher, Principal, Para, Specialist, etc.)

Health Care (MD, Nurse, Dentist, etc)

Mental Health (Therapist, Counselor, Psychiatrist, etc.)

Social Services/Community-Based Work

Faith-Based Clergy

College/University Student

Creative (Artist)

Technology

Food Services

Retail

Other:

Number of Hours Working Per Week *

0-20

21-40

41+

Which best describes your current transportation situation? *

Personal Car

Access to a shared car

No access to a car at all

What is your annual household income? *

Less than $25,000

$25,001 - $50,000

$50,001 - $100,000

$100,001 - $200,000

More than $200,001

Faith / Religion / Spiritual identity *

Christian (Catholic protestant or any other Christian denominations)

Buddhist.

Hindu.

Muslim.

Jewish.

Sikh.

No Religion.

Any other religion (Please specify)

Sexual Identity/Sexual Orientation (select all that apply):

Heterosexual

Lesbian

Gay

Bisexual

Trans

Queer

Asexual

Intersex

Other:

Family / Home Composition *

Nuclear Family

Single-Parent Family

Extended Family

Childless Family

Step Family

Grandparent Family

Do you have health insurance? *

Yes

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