Clone of Appa Interest Form (2026)

1

Please confirm your full name.* This field is required.

First Name

Last Name

2

What is your phone number?* This field is required.

Please enter a valid phone number.

3

What is your teen's name? * This field is required.Please complete one form per student.

First Name

Last Name

4

Which school does your teen attend?* This field is required.Start with the district, then select the school.

5

If Other, please describe

6

Please provide your teen's phone number.* This field is required.If your teen does not currently have their own phone, you may provide your number if you agree to allow your teen to contact their mentor.

Please enter a valid phone number.

7

Great! Does anyone else use your teen’s phone number?* This field is required.

YESNO

8

Got it! Who else uses this number?* This field is required.

You or another guardian / caregiver

Someone else (e.g. sibling)

9

Does {whatIs32[1]} read and understand English or Spanish at a 5th grade level or higher?

YESNO

10

Research Interest (Optional)* This field is required.We are partnered with Johns Hopkins University (JHU) on a National Institute of Mental Health (NIMH) funded project to learn more about student well-being. Parents/guardians and teens can choose to take part by completing surveys while using Appa. For each survey there is a gift card compensation. If your teen is interested in participating, would you be okay with being contacted to learn more? Someone from the JHU team may reach out by call or text to share details and answer any questions. Learning more is completely optional, and you can always change your mind later. Choosing not to learn more won’t affect your teen’s use of Appa services, including choosing a mentor.

Yes, I’d like to learn more!

No, not right now.

11

Great! Here are the times the JHU team is available to contact you.* This field is required.Please select all that apply

Tuesday: 10:00 am-1:00pm PST

Tuesday: 3:30pm-6:30pm PST

Wednesday: 10:00 am-1:00pm PST

Wednesday: 3:30pm-6:30pm PST

Thursday: 10:00 am-1:00pm PST

Thursday: 3:30pm-6:30pm PST

None of the above

12

Please let us know any day(s) and time(s) that work better, and anything else you’d like Johns Hopkins to keep in mind when contacting you.* This field is required.

13

Terms and Conditions* This field is required.By checking the box, you acknowledge that Appa is a mentorship program and is not a substitute for professional mental health services or other support systems. (Al marcar la casilla, usted reconoce que Appa es un programa de mentoría y no sustituye a los servicios profesionales de salud mental ni a otros sistemas de apoyo.)

14

Terms and Conditions* This field is required.By checking the box, you acknowledge that Appa is a mentorship program and is not a substitute for professional mental health services or other support systems. (Al marcar la casilla, usted reconoce que Appa es un programa de mentoría y no sustituye a los servicios profesionales de salud mental ni a otros sistemas de apoyo.)

15

Please provide some additional context about their reading level. Do you think your teen can read and understand these three words: accomplish, horizontal, unfamiliar

16

Research consent (optional)We are partnered with the researchers at Johns Hopkins, University of Washington, and UCSF to help improve mental health support for teens. If you have any questions about our research projects, email us at info@appahealth.com

17

Input Language

18

Navigator ID

19

School Pay

YESNO

20

Timezone

21

CWC

YESNO