What additional services/activities would you like offered in your community? Or, offered by HLVLE? (i.e gardening, exercise, nutrition, meditation, multicultural, etc.) Which Hope Lives Center location do you attend? Phoenix Flagstaff What types of information would you like to see presented on the website for HLVLE? What program(s) do/did you attend that you most enjoy? What has changed in your life since coming to HLVLE? I leave my house more often? I spend time with people I enjoy I have better housing I have encountered fewer barriers to obtaining housing I have reduced my recidivism to jail / prison I have reduced my criminogenic behavior (or negative involvement in the justice system) I have reduced my recidivism to suicide I have new skills that help me in living I have registered to vote I have participated in advocacy efforts I am more effective at self-advocacy I have food more often I am interested in work I have started preparing to work or go to school In which of these improvements has HLVLE played a part? Do you expect to return to work or school? Yes No What can HLVLE do to support your goals? survey questions to enter later Employment Self Assessment - Overall, how would you rate the following statements? Is working a goal on your ISP? Yes No If working IS a goal on your ISP, what supports and/or resources are listed as steps towards meeting your goal of working? How long have you been participating at Hope Lives? Less than 3 months (1 day - 90 days) More than 3 months but less than a year? (91 days - 365 days) 1 - 2 years Over 2 years What is your gender (select one)? Male Female Transgender Other What year were you born? Have you served in the armed forces/military? Yes No If you replied yes to the last question, are you receiving treatment of any kind as a result of active duty? Yes No Please choose the answer(s) that best describes your race/ ethnicity? (you may choose more than one) American Indian Asian Black or African American Hispanic / Latino Native Hawaiian or other Pacific Islander White Transracial Other Have you been told by a health professional (such as a doctor, psychiatrist, psychologist or nurse practitioner) that you currently have any of the following behavioral health disorders / mental illnesses? (please select all that apply) Mood Disorder (D/O), including Depression, Manic Depression, Bipolar or Affective Disorder Psychotic (Thought) Disorder, including Panic D/O, Phobias, Post Traumatic Stress D/O (PTSD) or Obsessive Compulsive D/O Personality Disorder, including Dissociative D/O / Multiple Personality D/O, Antisocial or Borderline Personality Disorder Substance Abuse Disorder(s) How much schooling did you complete? (select only the highest level completed) College degree (including technical school, Associate, Bachelor and/or graduate degree Attended college but did not receive a degree High school diploma or equivalent Attended high school but did not graduate Dropped out before high school Assigned to special education classes Survey to be entered later How many times in your LIFETIME have you been: Survey to be entered later Criminal History County or Reservation booked out of? County / Reservation released to? How many times have you been homeless for any length of time in the PAST 3 YEARS? Never (0) 1 - 3 Times 4 - 6 Times 7 or More Times Do you currently work for pay and if so how many hours per week do you typically work? (select only one) Employed (30 hours or more per week) Employed (30 hours or less per week) Not currently Employed Who employs you? Traditional employer Contract employment / seasonal Day labor Self employed Do you do volunteer work (without pay) at an organization or agency? Yes No In addition to your participation at Hope Lives, are you CURRENTLY attending any of the following? (Select all that apply) Work Adjustment Training / Pre-vocational program GED program Community College / University Hope Lab / A + certification Other During the PAST 90 DAYS where have you been living MOST OF THE TIME? My Apartment, house or mobile home Someone else's apartment, house, or mobile home Residential treatment program Half-way house or Recovery home Supervisory care home or boarding home Other Survey to enter later During the PAST 90 DAYS, have you.... remainder of form to be completed later Thank you!
