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Caregiver Burnout Workshop
Full Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
E-mail*
example@example.com
Are you currently pregnant?

YesNoUnsure
What is your gender?*

FemaleMaleNon-binaryDeclined to Answer
What ONE race do you identify with most?*

Black or African AmericanAsianWhite/CaucasianNative HawaiianNative AmericanPacific IslanderDeclined to AnswerOther
What is your ethnicity?*

Hispanic or LatinoNot Hispanic or LatinoDon't KnowDecline 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 ClinicBreast 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 year were you born?*
How did you hear about this event?*

Social Media (Facebook, Instagram, Twitter, etc.)CBWW StaffCBWW Email NewsletterCBWW WebsiteClinic/Healthcare AgencyCommunity Based OrganizationCommunity EventFriend/RelativeFlyer/PostcardGrady HospitalNewspaper/MagazineRadioOutreach Team
As a caregiver, who or what do you regularly provide care for? Select all that apply.

ChildrenBabiesElderlyFamilyEducationMedicalHome maintenance, like cleaning.My occupation involves caretakingOther
Where are your greatest concerns as a caretaker? Select all that apply.

Time managementFinancesEnergyMental healthSelf-careHealthSleepCaring for multiple individualsOther
Optional: Let's us know what you are interested in and we will follow up with you!

Healthcare -Primary Care, Gynecology, STI TestingMammograms Healthcare (Breast Cancer Screening)Behavioral Healthcare -Counseling, PsychiatryHealth Education/SeminarsEntrepreneurship/Financial LiteracyPrenatal & 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)
Are you okay with us sending you text reminders leading up to the event?*

YesNo
Should be Empty:

Caregiver Burnout Workshop