APCC Mental Health Community Education & Conversations Registration Form
Today's Date
mm/dd/yyyy
First and Last Name
*
E-mail
*
Phone Number
What mental health services are you interested in?
*
Attend Mental Health Community Education Workshops
Sponsored costs and referral to Mental Health counseling
Tailored and facilitated community education workshops with my community group.
Youth Advisory Council (I-WAC)
How did you hear about our services?
*
Zip Code of Residence
*
City of Residence
*
Age
*
Gender
*
Female
Male
Gender X (I do not identify as either exclusively male or female)
Unknown
Race
*
Black or African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
White
Two or More
Other Race
Unknown
Race Specific for AANHPI
Bangladeshi
Bhutanese
Burmese
Cambodian
Chinese
Fijian
Filipino
Guamanian or Chamorro
Hmong
Indonesian
Japanese
Korean
Laotian
Malaysian
Marshallese and people of Melanesia
Micronesian
Mongolian
Native Hawaiian
Nepalese
Okinawan
Pakistani
Polynesian
Samoan
Sri Lankan
Taiwanese
Thai
Tongan
Vietnamese
Ethnicity
*
Hispanic or Latino
Non-Hispanic or Latino
Unknown
Housing Status
*
Institutional Situations (live-in rehab facilities providing therapy for substance abuse, mental illness, or other behavioral problems)
Homeless situations (being at risk of losing housing; without a permanent house, housing, or place to live)
Stably Housed (having a stable and permanent place to live)
Unknown (You are not sure, which is okay.)
Veteran Status
*
Veteran
Non-Veteran
Unknown
Health Insurance Status
*
Medicaid
Medicare
Employer-Sponsored Disability Insurance
Private or Group Health Insurance
Veterans' affairs/Military
No insurance/Self-Pay
Unknown
Employment Status
*
Employed
Unemployed
Unable to work
Homemaker
Student
Retired
Unknown
*
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