Yale Wellness Reform Survey

You can always press Enter⏎ to continue

Now create your own Jotform - It's free!Create your own Jotform

This form is encrypted.

Elis for Rachael: Yale Wellness Reform Survey

Elis for Rachael: Yale Wellness Reform Survey

Rachael Shaw-Rosenbaum ’24, a first-year student in Branford College, died by suicide in March. As her family, friends, and the Yale community mourns her loss, together we see an opportunity to reform mental health policy at Yale. The current policy discouraged Rachael from obtaining the help she felt she needed. Rachael would want us to advocate for the next student in need. Click "start" to learn more about how you can help.

1
NameOptional
First Name
Last Name
2
EmailOptional
example@example.com
3
Phone NumberOptional
Area Code
Phone Number
4
Twitter handleOptional
5
Facebook handleOptional
6
Yale Affiliation* This field is required.Required
Alumnus: I graduated from Yale.
Student: I'm currently enrolled at Yale.
Previous student: I completed at least one semester at Yale, but I am not currently enrolled and did not graduate.
I'm a family or friend of a current/previous student or alumnus.
7
Name of the Yale student / alumnusOptional
First Name
Last Name
8
What school(s) did you attend / are you currently attending?Optional
Yale College
Yale Graduate or Professional School
Non-degree program at Yale
9
Select the school(s) that your family member / friend attended.Optional
Yale College
Yale Graduate or Professional School
Non-degree program at Yale
10
Class yearOptional. Multiple degrees? Enter the most recent class year.
11
Original class yearOptional
12
Do you want to share your or your loved one's personal experiences with mental health at Yale?Optional. Answering 'yes' to this question will prompt additional optional questions. Your responses are confidential and will not be shared without your consent.
YESNO
13
Did you or your loved one attend therapy at Yale?Optional
YESNO
14
Describe your / your loved one's experience with therapy at Yale.Optional
Huge
Large
Normal
Small
Ok
Ok
15
Did you or your loved one take a medical withdrawal at Yale?Note that a medical withdrawal is different from a leave of absence. A medical withdrawal happens after the first 15 days of the semester and requires a reinstatement / readmission process to return to Yale. A leave of absence must be requested during the first 15 days of the semester (or before). Leave of absences do not require an explanation and reinstatement is not required.
Yes
No, but the option was considered
No and the option was not considered
16
Why did you or your loved one not take the medical leave?Optional
17
Please describe the outcome with readmittance / reinstatement that you or your loved one experienced:Optional
Reapplied one time only and was granted readmittance / reinstatement the first time.
Denied readmittance at least once before being readmitted to Yale.
Denied readmittance one or more times and never returned to Yale.
18
Did Yale explain why readmittance / reinstatement was denied?Optional
YESNO
19
What would you like to share, about your/your loved ones experiences with contemplating withdrawal policies? What challenges did you face? What helped or would have helped? How was the experience with the medical withdrawal process and readmittance / reinstatement.Optional
20
Did any mental health support systems or leave practices at Yale leave a positive impression on you?Optional
21
What changes to mental health withdrawal policies or mental health practices at Yale in general would you like to see?Optional
22
How would you like to get involved?Optional (Scroll down to see all options)
I'd like to share my/my loved one's experience confidentially.
I'd like to share my/my loved one's experience publicly in writing. (Note, we will not share any details you provided without your consent).
I'd like to share my/my loved one's experience at a press conference.
I'd like to sign the Yale Wellness Reform petition when it is ready.
I'd like to share content on social media to help this cause, including petition, news articles, etc.
I'd like to donate to help Rachael's family.
I'd like to donate to help other students struggling with mental health issues at Yale.
I'd like to join an alumni group to provide emotional support to students struggling with mental health issues at Yale.
I'd like to assist with PR efforts.
I want to be involved, but I'm not sure how I want to help at the moment. Please stay in touch with me.
23
How else would you like to get involved?Optional
24
What additional comments or condolences would you like to share?Optional
25
Do we have your consent to use the information you provided regarding your experiences with Yale Mental Health services in our advocacy efforts? We will not include your name without your express permission.
YESNO
Should be Empty:

Yale Wellness Reform Survey

[Edit]

Question Label

1 of 25See AllGo Back

Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR

Already have an account? LOGIN

Skip Create an Account

Save your progress

Name

Email Address

Password

I agree to theTerms of ServiceandPrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR

Username or email

Password

Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.