Healthy Minds Alliance Participant Registration Form
Information for this form is provided voluntarily. Host sites are required to report information about program participants. Data will be kept private and will be referenced periodically to evaluate the effectiveness of the program. We appreciate your cooperation in the completion of this form.
Enter the first 2 letters of your FIRST name
*
Enter the first 2 letters of your LAST name
*
Enter your birth year
Street Address
City/Town
State
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Primary Email Address
*
A copy of this form will be sent to this email address.
Cell Phone #
Work Phone #
Date of training I will Attend
*
-
Month
-
Day
Year
Date
Site
*
Please Select
OR-NAMI Clackamas-Casey Curry-QPR
Type of training?
*
Adult MHFA
Youth MHFA
QPR
SafeTALK
NAMI Peer-to-Peer
Other
Employment Information
Are you a health professional?
*
Yes
No
Health Profession
Employer_
Choose your health profession
Please Select
Allopathic Medicine
Behavioral Health - Clinical Psychology
Behavioral Health - Clinical Social Work
Behavioral Health - Counseling Psychology
Behavioral Health - Marriage and Family Therapy
Behavioral Health - Other [specify in column M]
Behavioral Health - Other Psychology Social Work or Substance Abuse/Addictions Counseling
Chiropractor
Clinical Lab Worker
Community Health Worker
Dental Assistant
Dentistry - Dental Hygiene
Dentistry - General Dentistry
Facility Administrator
First Responder/EMT
Health Education Specialist
Health Education/Behavior
Health Informatics/Health Information Technology
Health Information Systems/Data Analysis
Health Services/Hospital Administration
Home Health Aide
Medical Assistant
Medical Interpreter
Medicine [doctor] - Family Medicine
Medicine [doctor] - Geriatrics
Medicine [doctor] - Internal Medicine
Medicine [doctor] - Other [specify in column M]
Medicine [doctor] - Pediatrics
Medicine [doctor] - Preventive Medicine/Public Health
Medicine [doctor] - Psychiatry
Midwife
Nursing - CNA, PCA
Nursing - Licensed practical/vocational nurse (LPN/LVN)
Nursing - NP [incl. APRN] - Adult
Nursing - NP [incl. APRN] - Family
Nursing - NP [incl. APRN] - Pediatrics
Nursing - Other [specify in column M]
Nursing - Registered Nurse
Nutritionist/Dietitian
Occupational Therapy
Office/Support Staff
Optometry
Osteopathic General Practice
Pharmacy/Pharmacist
Physical Therapy
Physician Assistant
Podiatry
Public Health - Disease Prevention & Health Promotion
Public Health - Environmental Health
Public Health - Epidemiology
Public Health - General Studies
Public Health - Health Policy & Management
Public Health - Infectious Disease Control
Research
Veterinary Medicine
Other [specify in the next field]
Other
Health Profession not listed above
Do you work in a medically underserved area?
Yes
No / Unsure
Do you work in a primary care setting?
Yes
No / Unsure
Do you work in a rural setting?
Yes
No / Unsure
Employment Information (cont.)
Employer
Profession
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Race, Ethnicity, and Military Service
Gender
Please Select
Male
Female
I identify as neither male nor female
Race
Please Select
American Indian/ Alaskan Native
Asian
Black
Hawaiian/ Pacific Islander
White
More than one race
Not Available
Ethnicity
Please Select
Hispanic
Non Hispanic
Not Available
Military Service
Please Select
Active Duty Military
Veteran
Military Family Member
Veteran Family Member
None
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Survey
1. How knowledgeable are you about mental health issues?
1. Not at all
2. Slightly
3. Somewhat
4. Moderately
5. Extremely
2. How confident are you helping a person who is demonstrating signs or symptoms of a mental health issue.
1. Not at all
2. Slightly
3. Somewhat
4. Moderately
5. Extremely
3. How knowledgeable are you about strategies to use to help a person with a mental health issue?
1. Not at all
2. Slightly
3. Somewhat
4. Moderately
5. Extremely
4. How able are you to promote help seeking behaviors of a person who is demonstrating signs or symptoms of a metal illness?
1. Not at all
2. Slightly
3. Somewhat
4. Moderately
5. Extremely
5. People with mental health issues should be avoided.
1. Strongly Disagree
2. Disagree
3. Neutral
4. Agree
5. Strongly Agree
6. If I had a mental health issue I would not tell anyone.
1. Strongly Disagree
2. Disagree
3. Neutral
4. Agree
5. Strongly Agree
7. People with mental health issues are dangerous.
1. Strongly Disagree
2. Disagree
3. Neutral
4. Agree
5. Strongly Agree
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