Soul Care Sessions Event Sign Up

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Full Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Which of the following best represents your racial or ethnic heritage?* This field is required.

Black or African American

White

American Indian

Asian American

Other Pacific Islander

Others

4

Do you live and/or work in Ramsey County?* This field is required.

Live

Work

Both, Live & Work

Neither, Live or Work

5

Are you familiar with Ramsey County mental health services?* This field is required.

YESNO

6

Are you a mental wellness provider, whether traditional or nontraditional?* This field is required.

YESNO

7

What type of services do you provide?

8

Are you interested in learning about contracting with Ramsey County?* This field is required.

YESNO

9

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10

Do you consent to the media release?* This field is required.I acknowledge that I am at least 18 years old and have the right to enter into this agreement. If I am under 18 years old, I understand that a parent or legal guardian must also sign this release on my behalf. For any questions or concerns regarding this release, please contact: C.A. Ellis & Associates, LLC info@caellisassociates.com

YESNO

11

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