Be Paid to Share Your Story💸🗣️

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🤔 What is this? 🤔We are #TheTeaInLBL Youth Advisory Council, a group of young people in Linn, Benton, and Lincoln counties in Oregon that come together to listen to the voices of young people giving their feedback on systems that have served them (Ex: education, juvenile justice, child welfare, and more). "Be Paid to Share Your Story" is at its core, a conversation. The goal is to hear what worked, what didn't work, and overall any gaps/barriers that you've encountered in your own experience, and be paid a $25 Visa Gift Card for 1 hour of your time. It can be in-person, on Zoom, over the phone, whatever works best for you. If you're interested thus far, keep on clicking through this survey to see if it is a good fit for you 🌞
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Are you eligible to participate?* This field is required.If you are not within our age range or region, unfortunately we cannot more forward with your request, but we do invite you to reach out to us at 971-275-5450(calls or texts) or at theteainlbl@youthera.org for support finding other resources & opportunities in your area 🙂
I am between the ages of 14-25 years old 🌱
I live in Linn, Benton, or Lincoln county in Oregon 🗺️
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How would you like to have this conversation?Since this is a reflection on your experience receiving care, it is important that this not be done by oneself (so a supportive person can be available to help). This is where your preference comes in, you can either have this conversation with Nate, our council coordinator, or it can be with a trusted person in your life (a therapist, teacher, parent, friend, whoever you feel the most comfortable with).
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How would you like to have this conversation?* This field is required.If you choose to meet with Nate, you'll be guided through a few questions to schedule a time to meet. If you choose to meet with someone you know, you're invited to pause filling out this form until you're ready to have the conversation. Please note that if you choose to meet with someone you know, they will also be asked to share information about themselves for our records (name, contact information for questions & payment)
With Nate (council coordinator)👍
With someone you know who (Ex: therapist, friend, parent, teacher, probation officer, etc.)👍
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Privacy & ConfidentialityThe purpose of this opportunity is to hear what's working and what's not working in the systems that serve young people, so it can be communicated out and worked on by our council and others. Young people who partake in this opportunity will be asked questions that elicit responses containing sensitive, personal information, including Protected Health Information (PHI). Information shared on the this survey is encrypted & stored in an electronic database. All written / documented information on your experience is to be redacted of PHI (meaning any information that identifies you, as you, will be taken out) and before anything is shared to others, you will be asked to review and consent to the notes being shared. You can edit anything that is written down, and you have the option to choose if you want the name of the places that served you to be included.
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Mandatory ReportingWe want to be upfront with you, we are Mandatory Reporters, meaning we are required by law to report suspected child abuse or neglect when we have reasonable cause to believe it has occurred. This is an exception to confidentiality. We invite you to keep this in mind, and only share what you feel comfortable sharing with us given this knowledge. If you have any questions or concerns, please feel free to share them on this form or contact us at 971-275-5450(calls & texts) or theteainlbl@youthera.org 💞
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For You* This field is required.I understand that the information I share will be kept private except in cases where there is a legal or safety concern (for example: if someone is being hurt, plans to hurt themselves, or plans to hurt others). In those cases, the person I am talking with is required to report it to keep people safe.
I understand what was shared and consent to moving forward ✅
I do not understand what was shared and want to pause on moving forward until I can meet with Nate to answer any & all questions ❌
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To be completed by the Person You Know* This field is required.As the person helping collect these notes, I agree to keep the youth's story private. I also understand that if the youth shares something that makes me worried about their immediate safety (for example: abuse, neglect, or serious risk of harm), I will immediately contact Nate at 971-275-5450(calls or texts) or theteainlbl@youthera.org. If I work as a professional, I also understand that I am responsible for following both my organization’s policies and the confidentiality and mandatory reporting requirements outlined here.
I understand what was shared and consent to moving forward ✅
I do not understand what was shared and want to pause on moving forward until I can meet with Nate to answer any & all questions ❌
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Tips & Tricks for you 🌠The goal is that this conversation will feel informal and organic to have. With that said, it is okay and normal if it feels awkward at first or the whole time. At any point if you want to pause, take a break, or stop altogether, you have that right and are encouraged to do so. You have the right to decline to answer any question, or only answer partially. Remember, the idea is to share what was helpful for you in receiving the care that you did (what you feel more young people should have access to), what wasn't helpful for you (what you feel other young people shouldn't have to deal with), and any gaps/barriers you've experienced (areas you wish you could have received support in but it wasn't available or there was an obstacle in your way). This does not need to be done in one-go, and to respect your time, please do not exceed 1 hour without contacting Nate first to ensure funds are available to pay you for an additional hour.
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Tips & Tricks for the person you're talking with 🌠Stay judgement free, this is not the time to share our opinion. Right now we are listening to hear what is being said, not listening to respond. Before you ask any follow-up questions on an experience, make sure you ask for consent of the young person (Ex: "You mentioned _, are you comfortable to share more about that?"). This conversation should not feel formal or artificial, it is okay to deviate from these questions and talk organically, then circle back to take notes. If the young person you're talking to starts to become upset or stressed, please take a break and decide together whether or not to come back to the conversation later. This does not need to be done in one-go, and to respect both of yours' time, please do not exceed 1 hour without contacting Nate first to ensure funds are available to pay for an additional hour.
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What is the date? 🗓️* This field is required.
Date
Year
Month
Day
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What's your name? 🤔* This field is required.This can be your legal name or your preferred name, and please include your pronouns in the "First Name" box if that's important to your identity
First Name
Last Name
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What's the name of the person you're talking with? 🤔* This field is required.This can be your legal name or your preferred name, and please include your pronouns in the "First Name" box if that's important to your identity
First Name
Last Name
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What is your email? 📨Its okay if you don't have one, we'll ask about phone number next if that's more relevant for you
example@example.com
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What is the email of the person you're talking with? 📨Its okay if you don't have one, we'll ask about phone number next if that's more relevant for you
example@example.com
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What is your phone number? 📲Its okay if you don't have one (if you don't have a phone number or email, please share at the end on the "Anything Else❔" question how we can get ahold of you)
Please enter a valid phone number.
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What is the phone number of the person you're talking with? 📲Its okay if you don't have one (if you don't have a phone number or email, please share at the end on the "Anything Else❔" question how we can get ahold of you)
Please enter a valid phone number.
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How old are you? 🐣* This field is required.
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Which county in our region do you live in (or have experience receiving care in)?* This field is required.
Linn County
Benton County
Lincoln County
I don't know
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What system(s) did you receive care from in Linn, Benton, or Lincoln county & want to "share your story" about? 🏫🚓🏥🏡💭* This field is required.Examples: Juvenile Justice (having a probation officer, getting into legal "trouble", encountering law enforcement) ; Education (going to public, private, charter, or even home school) ; Child Welfare (talking with a DHS caseworker, living in foster/resource homes) ; Mental Health (talking with a therapist or skills trainer, taking medicines to help with your mental health) ; Medical System (going to the doctor, being in the hospital, taking medicines to help with your overall health) ; Other (can include the recovery support, being unhoused, having an intellectual or developmental disability, and more)
Juvenile Justice System 🚓
Mental Health System 💭
Education System 🏫
Medical System 🏥
Child Welfare System 🏡
Other (not listed)
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What worked for you in receiving care in the Juvenile Justice System 🚓?* This field is required.What was helpful, supportive, compassionate, life-saving, or overall you think more young people should have access to
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What didn't work for you in receiving care in the Juvenile Justice System 🚓?* This field is required.What was annoying, demeaning, harmful, life-threatening, or overall do you think young people should not experience
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What gaps / barriers did you run into in the Juvenile Justice System 🚓?* This field is required.What did you want to get / could have benefited from receiving to better help you & your life, but you were unable to due to the gap/barrier
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What worked for you in receiving care in the Mental Health System 💭?* This field is required.What was helpful, supportive, compassionate, life-saving, or overall you think more young people should have access to
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What didn't work for you in receiving care in the Mental Health System 💭?* This field is required.What was annoying, demeaning, harmful, life-threatening, or overall do you think young people should not experience
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What gaps / barriers did you run into in the Mental Health System 💭?* This field is required.What did you want to get / could have benefited from receiving to better help you & your life, but you were unable to due to the gap/barrier
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What worked for you in receiving care in the Education System 🏫?* This field is required.What was helpful, supportive, compassionate, life-saving, or overall you think more young people should have access to
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What didn't work for you in receiving care in the Education System 🏫?* This field is required.What was annoying, demeaning, harmful, life-threatening, or overall do you think young people should not experience
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What gaps / barriers did you run into in the Education System 🏫?* This field is required.What did you want to get / could have benefited from receiving to better help you & your life, but you were unable to due to the gap/barrier
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What worked for you in receiving care in the Medical System 🏥?* This field is required.What was helpful, supportive, compassionate, life-saving, or overall you think more young people should have access to
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What didn't work for you in receiving care in the Medical System 🏥?* This field is required.What was annoying, demeaning, harmful, life-threatening, or overall do you think young people should not experience
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What gaps / barriers did you run into in the Medical System 🏥?* This field is required.What did you want to get / could have benefited from receiving to better help you & your life, but you were unable to due to the gap/barrier
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What worked for you in receiving care in the Child Welfare System 🏡?* This field is required.What was helpful, supportive, compassionate, life-saving, or overall you think more young people should have access to
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What didn't work for you in receiving care in the Child Welfare System 🏡?* This field is required.What was annoying, demeaning, harmful, life-threatening, or overall do you think young people should not experience
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Large
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Small
Ok
Ok
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What gaps / barriers did you run into in the Child Welfare System 🏡?* This field is required.What did you want to get / could have benefited from receiving to better help you & your life, but you were unable to due to the gap/barrier
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What worked for you in receiving care in an "Other" system not listed?* This field is required.What was helpful, supportive, compassionate, life-saving, or overall you think more young people should have access to
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What didn't work for you in receiving care in an "Other" system not listed?* This field is required.What was annoying, demeaning, harmful, life-threatening, or overall do you think young people should not experience
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Ok
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What gaps / barriers did you run into in an "Other" system not listed?* This field is required.What did you want to get / could have benefited from receiving to better help you & your life, but you were unable to due to the gap/barrier
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Ok
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Anything Else ❔Is there anything else you would like to ask a question about, share, or for us to keep in mind? Remember if you didn't share before, please let us know how we can get ahold of you and the person you're talking with 😊
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Ways to Get Paid Your $25 Visa Gift Card 💸🗣️Now that you've completed your 1 hour reflection, you deserve to be compensated for your time doing so! This is paid via a $25 Visa Gift Card, which works like any other Visa debit card and can be used anywhere they can be used. Now, you have two options to choose from to get paid. You can do a digital gift card, which means it will be sent to your email. Digital gift cards have their limitations, and cannot be used at a grocery store, added to a mobile wallet, or other uses. It can essentially only be used to buy things online, but you will likely receive it faster than the other option. Your other choice is a physical gift card, that is mailed to the address you will be asked to provide given you decide to do this option. The only down side is can takes ~3-5 business days to arrive. It is up to you what you prefer, please consider what you plan to use the money for and choose the option that works best for your situation 🥰
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How do you want to be paid your $25 Visa Gift Card?* This field is required.
Digital Gift Card 💻
Physical Gift Card 📫
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What is the email address you want your gift card to be sent to? 💻* This field is required.Pleaseeeeeeee double check spelling to make sure it is sent to the correct email, we recommend double checking 🙏
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
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What is the mailing address you want your gift card to be sent to? 📫* This field is required.Pleaseeeeeeee double check spelling to make sure it is sent to the correct address, we recommend double checking 🙏
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Alright that's everything! Thank you for the time and please reach out to the contact information below if you have any questions & we'll follow-up shortly🙂Nate Lattanzio - LBL Youth Advisory Council Coordinator ; 971-275-5450 (calls & texts) ; theteainlbl@youthera.org
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What is the date? 🗓️* This field is required.
Date
Year
Month
Day
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What's your name? 🤔* This field is required.This can be your legal name or your preferred name, and please include your pronouns in the "First Name" box if that's important to your identity
First Name
Last Name
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What is your email? 📨Its okay if you don't have one, we'll ask about phone number next if that's more relevant for you
example@example.com
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What is your phone number? 📲Its okay if you don't have one (if you don't have a phone number or email, please share at the end on the "Anything Else❔" question how we can get ahold of you)
Please enter a valid phone number.
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How old are you? 🐣* This field is required.
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Which county in our region do you live in (or have experience receiving care in)?* This field is required.
Linn County
Benton County
Lincoln County
I don't know
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What system(s) did you receive care from in Linn, Benton, or Lincoln county & want to "share your story" about? 🏫🚓🏥🏡💭* This field is required.If you do not understand this question, that is okay, click the "I don't know" and we'll help explain when we follow-up with you. If your system is not listed, please share what system it was on the "Anything Else❔" question
Juvenile Justice System 🚓
Medical System 🏥
Education System 🏫
Child Welfare System 🏡
Mental Health System 💭
Other (not listed)
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Could you briefly share a bit about what you plan on sharing? 🙏* This field is required.Please don't spend a bunch of time on this, max 2-3 sentences because you deserve to be paid for your reflection
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When would be a good time to meet? 🗣️* This field is required.IMPORTANT: Scheduled times will need to be confirmed on our end to make sure we can also meet you at that time, so please share a good day & time here, and give us a backup option if you could on the next question
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If that time doesn't work, is there another time that could? 🗣️OPTIONAL: It is just helpful to have a backup option incase we can't meet at that time 🙂
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How do you want to meet? 🚗🧑‍💻* This field is required.We can come to you, or the internet can bring us together via Zoom, however you'd feel most comfortable
In-Person
Virtual (via Zoom)
Phone Call
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Do you have any questions you would like answered? Or anything you'd like to share regarding sharing your story before we meet? 🫡We will make sure to answer any and all questions when we reach out to confirm a time to meet
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How are you feeling about all this?
What's the vibe?
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What's the vibe?
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Anything Else ❔Is there anything else you would like us to keep in mind? Remember if you didn't share before, please let us know (1) how we can get ahold of you, and (2) what system you received care from if it wasn't listed. Also please let us know if you require any accommodations, we are happy to meet you where you are at 😊
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I understand that the #TheTeaInLBL Youth Advisory Council has a finite amount of funding 💰, and though it will do its best to meet with every young person that submits this form, it may not be able to immediately 💖* This field is required.If for whatever reason we can't right away, we will ask you if we can hold onto your request to then contact you when we are able to meet with you!
Makes sense 👍
Doesn't Make Sense 👎 (we'll share more info when we follow-up with you)
Should be Empty: