Riverside County Department of Mental Health Mental Health Services Act Community Services and Supports 3-Year Plan

Feedback Form

Please submit this form by December 16, 2005. Forms can be submitted online at http://mentalhealth.co.riverside.ca.us/opencms/english/mhsa/ or mailed to: Riverside County Department of Mental Health, MHSA CSS Evaluations, PO Box 7549, Riverside, CA 92513.

What do you feel are the strengths of the plan? Please identify the
program and age group, if applicable.

What concerns do you have about the plan? Please identify the
program and age group, if applicable.

What region do you live in?
Desert (Banning, Indio, Blythe, etc.)
Mid-County (Hemet, Lake Elsinore, Perris, Temecula, etc.)
Western (Corona, Riverside, Moreno Valley, etc.)

What group are you most associated with?
A consumer of mental health services
A family member of a consumer
County Employee
Law Enforcement
Education
Human Services
General Community

What is your gender?
Male
Female

What is your ethnicity?
African American/Black
American Indian/Native American
Asian/Pacific Islander
Caucasian/White
Hispanic/Latino/Chicano
Other. Please specify:

What is your age?
0-17 yrs 18-24 yrs 25-59 yrs 60+ yrs

Overall, how do you feel about the plan?
Very Satisfied Somewhat Satisfied Satisfied Unsatisfied Very Unsatisfied