Registration Form
Fill out the form carefully for registration. The East Bay Regional Coalition is providing mental health awareness trainings through funding provided by SAMHSA. Participants who receive free training will be better able to offer resources to people in need. We will track these referrals to resources and treatment over the next 5 years.
Name
*
First Name
Middle Initial
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Mobile Number
We would like to learn more about Portuguese community attitudes towards mental health so that we can create a culturally appropriate training. If you identify as Portuguese, will you help us by filling out a separate, anonymous survey about this? (We will mail).
Yes, I identify as Portuguese and will fill out the survey. Please send an ENGLISH version.
Yes, I identify as Portuguese and will fill out the survey. Please send a PORTUGUESE version.
No, I am not interested.
How did you hear about the training?
Referred by a friend
Referred by workplace
Social media
Other
Which type of training do you prefer?
Self-paced online module
Live, in-person option
Live, remote option on Zoom
Choose the training date:
xxx (live, in-person)
Submit Application
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