Expression of Interest Form

Expression of Interest

Fill the form below to follow the MEND Allies group and to receive more details on how to join us and contribute to our cause.
Name: *

Prefix First Name Last Name Suffix
E-mail Address: *
example@example.com
Phone Number: *

Area Code Phone Number
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you a mental health provider? *

PhD PsyD MD PNP LCSW LCAS LMFT LPC Pre-licensed I’m not a mental health provider
Racial Identity *

Alaskan native/Native American Asian African-American/black White Hispanic Latinx Middle Eastern
Are you interested in becoming a MEND Ally?

Yes No Unsure
Any special talents or contributions that you are interested in lending to the mission?
Ally Donation

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USD Description
Solidify your interest in MEND with a financial contribution to our cause. At this time, we are allowing values-based contributions. While we have suggested a donation amount $125 per individual, we urge you to give based on your ability and the value that you place on seeing people of color liberated from the effects of trauma. Every single dollar that we collect moves us closer to a person in need of healing.

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.