NDoula Health Equity Assessment

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All responses are kept confidential and any reporting will be anonymous.

In an effort to understand community needs, pls share your opinions and experiences.

For each category, consider your needs and the needs of your community. How well does your community's resources provide the following?

Name (required)

Age (required) *

Email (required)

Zip code (required) *

I am filling out this form for

Myself

Someone else

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Check ALL you self-identify as: *

Birthing person or birthing capable person

Black

Person of Color

White

Woman

Gender Non Conforming

Queer-identifying

Medically vulnerable (chronic illness, mental/emotional illness, substance use disorder, disability, etc.)

Currently eligible for public assistance (Medicad, TANF, SNAP, etc) regardless if you receive it or not

Caregiver

Required

Self-identify (optional)

I, or someone I know, would benefit from more:

culturally reflective healthcare

culturally reflective care providers

trauma-informed care

holistic violence prevention recommendations

medical support

patient-centered care approaches

medical teamwork

reproductive & sexual healthcare

patient advocacy

Please use this space for feedback on programs you'd like to see, areas of care needing more support in Chicagoland, or comments of your choice (optional).

Would you like to receive our quarterly newsletter?

No, thank you.

Thank you for filling out this questionnaire.

-NDoula Community Alliance

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