Strengths Building & Wellness for My Caribbean Mind Registration
Thank you for Registering. We look forward to Welcoming you! (information provided here will be maintained as confidential, and not shared with any third parties,unless required by a court order or law enforcement.)
Your Name
*
First Name
Middle Name
Last Name
E-mail Address (personal)
*
example@example.com
Phone Number (Cellphone)
*
Format: (000) 000-0000.
Sexual Orientation (how do you identify?)
Please Select
Heterosexual/Straight
Homosexual/Same-Gender Loving, Gay, Lesbian, Bisexual
Transgender/Intersex
Non-Binary
Prefer Not to Disclose
Gender Identity (how do you identify?)
Please Select
Female/Cis-gender Female
Male/Cis-gender Male
Transgender
Gender Non-Conforming
Prefer Not to Disclose
Age (as a range)
18 to 25
26 to 35
36 to 45
46 to 55
56+
Educational Attainment
High School (GED)
Some College
College Graduate (Associate's and Bachelors)
Post Graduate (Masters, Doctorate)
Vocational Profession (carpenter, mechanic, plumber, electrician, security guard)
By participating in this workshop experience, what are you looking forward to - your expectations? (select one and or all responses)
to improve/update my knowledge about mental health and self care
to learn about signs and symptoms, and responding to a family member, friend, co-worker, colleague in need
to learn about taking care of myself, recognizing the signs and symptoms when I may be experiencing distress and heading to a crisis
At the end of this workshop experience, I am committed to making changes in my life and assisting others with getting care. (select one and or all responses)
I'm committed to sharing about this workshop with family members, friends, colleagues, co-workers
Following this workshop, I'm committed to completing the evaluation
Following this workshop, I commit to looking into obtaining mental health care for myself
Would you like to remain in touch, for more mental health offerings (workshops, etc)?
Yes
Unsure
No
If yes, how would you like us to contact you?
Phone
Email
Phone and Email
Submit
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