1_HMAParticipant Registration 2020_OR_NAMI Clackamas_Casey_QPR

  • 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.
  • Date of training I will Attend*
     - -
  • Type of training?*

  • Employment Information

  • Are you a health professional?*

  • Health Profession

  • Do you work in a medically underserved area?
  • Do you work in a primary care setting?
  • Do you work in a rural setting?

  • Employment Information (cont.)

  • Race, Ethnicity, and Military Service

  • Survey

  • 1. How knowledgeable are you about mental health issues?
  • 2. How confident are you helping a person who is demonstrating signs or symptoms of a mental health issue.
  • 3. How knowledgeable are you about strategies to use to help a person with a mental health issue?
  • 4. How able are you to promote help seeking behaviors of a person who is demonstrating signs or symptoms of a metal illness?
  • 5. People with mental health issues should be avoided.
  • 6. If I had a mental health issue I would not tell anyone.
  • 7. People with mental health issues are dangerous.
  • Should be Empty: