First Name
Last Name
Email
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Comments
What brings you to this cause? (Check all that Apply). I currently have or have experienced a mental health or substance use condition. I have or have had a family member with a mental health or substance use condition. I have or have had a friend with a mental health or substance use condition. I am or have been a provider of mental health or substance use services. I am interested in mental health and substance use policy. NOTE: To select multiple items, press and hold the COMMAND / CTRL key, then click the items
What have you been impacted by? Substance Use Mental Health Both
Please share how you and your family are impacted by mental health or substance use.
Are you interested in (check all that apply): Legislative Advocacy Local Media Opportunities Social Media Opportunities Fundraising Volunteering Programming Providing Feedback on policy NOTE: To select multiple items, press and hold the COMMAND / CTRL key, then click the items
Policy Issues of interest: (check all that apply) Strong start for all children Support for families Access to housing, health care, supports, and services Reducing potential harms of drugs and alcohol Wellness in aging Decriminalizing mental health Ending discrimination Health Literacy and Health Promotion NOTE: To select multiple items, press and hold the COMMAND / CTRL key, then click the items
Which gender identity do you most identify with? Female Male Transgender female Transgender male Non-binary or gender fluid Other
Do you consider yourself part of the LGBTQIA+ community? Yes No
What is your age? Under 18 18-24 years old 25-34 years old 35-44 years old 45-54 years old 55-64 years old 65 and over
Which of the following best describes you? Check all that apply. American Indian or Alaska Native Asian Black or African American White or Caucasian Hispanic or Latino Native Hawaiian or other Pacific Islander Middle Eastern or African Other NOTE: To select multiple items, press and hold the COMMAND / CTRL key, then click the items
If you are comfortable doing so, please tell us the source of your health insurance. Please check all that apply. Employer-sponsored insurance Individual Insurance Marketplace Medicare Medicaid Tricare Not Currently Insured I don’t know Other NOTE: To select multiple items, press and hold the COMMAND / CTRL key, then click the items
Are you Currently a Student Yes No