Connectivity: vol 7, iss 1, Mental Health Survey

Please cut and paste, then email your response to editor@forge-forward.org or fax or snailmail your answers to 414-278-6034 or PO Box 1272, Milwaukee, WI 53201.

Thank you for your participation.

1. What types of mental health services have you received (at any point in your life)? (check all that apply)

__None
__Individual therapy
__Group therapy
__Social support group
__Hospitalization
__Professional services for addiction
__Psychotropic medication (e.g. Prozac)
__AA/NA/OA/Addiction self-help group
__Nutritional counseling (dietary changes to improve mental health)
__Bodywork/energy work
__Other ________________________________

2. If you have seen a therapist at any point in time, what was the primary reason(s): (check all that apply)

__Not applicable - no therapy
__Individual therapy
__Couples or relationship therapy
__To acquire a letter for hormones
__To acquire a letter for surgery
__Other _________________________________

3. If you have mental health issues, which category(ies) would best describe your issues (either self-classified or based on a professional diagnosis)? (check all that apply)

__Not applicable
__Gender Identity Disorder
__Depression
__Anxiety
__Adjustment Disorder
__Sleep Disorder
__Post Traumatic Stress Disorder
__Psychotic Illness
__Other _________________________________

4. If you are a SOFFA (Significant Other, Friend, Family, or Ally), have you sought professional help in dealing with trans issues?

__Yes, to deal with my partner/family member/friend's transness
__Yes, I needed to examine my own trans issues that came up when dealing with my loved one's
__No, but I have considered it
__No
__Not applicable
__Other _____________________________

5. Have you ever been prescribed a psychotropic medication for a mental health condition? (e.g. Prozac)

__Yes, currently taking medication
__Yes, took medication in the past
__No
__I have a prescription that I haven't yet filled
__Other ________________________________

6. If you have a mental health condition, how much has it interfered with your daily function?

__Not applicable
__Some
__Not at all
__A fair amount
__A little
__It is debilitating
__Other_________________________________

7. Do you attribute any mental health issues in your life as being related to being trans or being the SOFFA of a trans person?

__Not applicable
__A fair amount
__Not at all
__A significant amount
__A little
__100%/totally

8. Has a professional (psychotherapist, psychiatrist, physician, or other professional) ever denied you access to hormones or surgery because of a mental health condition?

__No
__Yes

If yes, what reason was stated? ______________________________________

If yes, did you get a "second opinion"?
__Yes __No

9. Have you ever INVOLUNTARILY received mental health services?

__No
__No, I don't believe so
__Yes

If Yes, what types of services did you receive without your consent?

__Therapy
__Hospitalization
__Medication
__Electroshock therapy
__Any "treatment" to address your gender identity
__Other _____________________________

10. Have you ever attempted suicide?

__No
__No, but I've considered it
__Yes

If yes, how many times _____

If yes, by what method(s) ____________________________

11. If you have a long term mental health condition and are on any form of hormones (testosterone, estrogen, progesterone or other - for reasons of birth control, HRT after menopause, same/dominant hormone enhancement, or "cross-gender" hormones), have you noticed if the hormones have had any effect on your mental health condition(s)?

__Not applicable
__None that I know of
__I have only had a mental health condition since after starting hormones
__My condition has improved
__My condition has gotten worse

12. What "techniques" do/have you use/d to maintain or improve your mental health?

__Therapy
__Body work
__Medication
__Energy work
__Journaling
__Crystals or rocks
__Exercise
__Meditation
__Herbal supplements
__Prayer
__Vitamins or supplements
__Diet
__Other __________________________

13. Do you have health insurance that covers mental health services?

__Yes, my health insurance covers mental health services
__No, my health insurance excludes mental health services
__I don't know
__I don't have insurance
__Other __________________________________

14. If your insurance does cover mental health services, how are those services restricted, if at all?

__Not applicable
__I have to select a therapist from a list of providers
__I can see any therapist
__I am only allowed a certain number of visits/sessions
__I can see a therapist for an indefinite number of sessions
__Other___________________________________

15. Age

__<18
__19-24
__25-34
__35-44
__45-54
__55-64
__65+

16. Where do you live?

__Urban
__Suburban
__Rural
__Other _____________________________

17. Economic influence

__Lower class
__Working class
__Middle class
__Upper middle class
__Upper class

__Student
__Disabled
__Retired

18. Relationship to the trans community

__I am trans+/genderqueer/butch/intersexed/questioning (+++)
__Significant Other
__Friend
__Family member
__Ally
__Helping professional
__Other ______________________________

19. Is there anything else you'd like to tell us about your mental health status or experiences?

Please send your survey responses no later than March 5 to Connectivity, PO Box 1272, Milwaukee, WI 53201, or fax to 414-278-6031. Survey results will be published in the next issue of Connectivity, expected to be published in March 2002. If you have questions or comments, please email the Connectivity editors at editor@forge-forward.org.

	Connectivity volume 7, issue 01
	Mental Health Survey