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HEAD HEART AND SOUL GROUP NEEDS ASSESSMENT

Needs Assessment Questionnaire Objectives

The purpose of this need assessment questionnaire is to assist The HEAD HEART AND SOUL GROUP to proactively plan and develop new relevant and timely materials to assist the counselors working in the addiction field.

Confidentiality

The personal information you provide by completing this survey will be used solely by The HEAD HEART AND SOUL GROUP. All personal information provided will be kept in the strictest confidence and will not be given to any third party. Thank you for taking the time to assist us to better serve you.

In oder to provide you with the best service possible, please be as complete as possible.

First Name:

Last Name:

Professional Designation:

Work Title:

Position Type:

Organization Name:

Email:

Cell Phone:

Telephone:

Street Address:

City:

Prov/State:

Country:

Postal Code / Zip:

Organization

Private

Non Profit

Public / Government

Sector

Client Base

Male

Female

Blend

Age Group:

Addiction Types (CTRL + Click for multiple choices):

Addictions Other:

Client Issues (CTRL + Click for multiple choices):

Client Issues Other:

Addictions encountered throughout career:

Continuing Education / Core Credits

Pharmacology

Specific drugs:

To further update your knowledge, do you feel it would be valuable to attend pharmacology workshops that focus exclusively on the evolving street drug scene?

Yes No

What courses or workshops would you like to see for continuing education and/or core credits? (CTRL + Click for multiple choices):