Nutrition & Brain Health Workshop
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Are you currently pregnant?
Yes
No
Unsure
What is your gender?
*
Female
Male
Non-binary
Declined to Answer
What ONE race do you identify with most?
*
Black or African American
Asian
White/Caucasian
Native Hawaiian
Native American
Pacific Islander
Declined to Answer
Other
What is your ethnicity?
*
Hispanic or Latino
Not Hispanic or Latino
Don't Know
Decline to answer
Have you been a CBWW client, patient, or participant before? Please select all that apply.
*
No. I have never been a CBWW client, patient, or participant before.
Yes, I am a current client.
Yes, I am a former client.
If you are a current or former client, please indicate which programs you have been a part of.
*
Wellness Clinic or Primary Care Clinic
Breast and Cervical Cancer Program (Example: Vision Board Workshops)
Behavioral Health Program (Example: yoga, Zumba)
Atlanta Healthy Start Initiative (including the Fatherhood Initiative)
COVID-19 Vaccination and Education
What is your age group?
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Under 18
18 - 21
22 - 30
31 - 40
41 - 54
55+
How did you hear about this event?
*
Social Media (Facebook, Instagram, Twitter, etc.)
CBWW Staff
CBWW Email Newsletter
CBWW Website
Clinic/Healthcare Agency
Community Based Organization
Community Event
Friend/Relative
Flyer/Postcard
Grady Hospital
Newspaper/Magazine
Radio
Outreach Team
Do you plan to attend the workshop in-person or virtual on Zoom?
*
In-person at CBWW (477 Windsor Street SW Atlanta, GA 30312)
Virtual on Zoom (The link will be emailed to you in your reminder emails.)
Not sure yet
Would you or someone you know be interested in sharing their experience with caring for a loved one with memory issues?
Optional: Please list any questions or comments you may have for the neurologist Dr. Brianna Burlock Powell.
Optional: Let's us know what you are interested in and we will follow up with you!
Healthcare -Primary Care, Gynecology, STI Testing
Mammograms Healthcare (Breast Cancer Screening)
Behavioral Healthcare -Counseling, Psychiatry
Health Education/Seminars
Entrepreneurship/Financial Literacy
Prenatal & Parenting Support (Pregnant or Mother with Children Under 18 months-Fulton County Residents Only)
Fatherhood Support (Having a Baby or have Children Under 18 months - Fulton County Residents Only)
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