Tea Time: Nutrition & Mental Health
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?
*
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
Optional: What are your top 3 favorite tea flavors?
Black
Green
Chamomile
Mint
Ginger
Chai
Fruit Tea Blends
Other
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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