About You

Welcome to Mind Matters!
Most of these questions are optional (except the ones with*) and your information will only be shared anonymously.

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1. Name of person who referred you

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2. Last Name (Required.)

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3. First Name (Required.)

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4. What name would like us to call you?

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5. Age Range (Required.)

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6. Year of birth? (Required.)

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7. *Cell Number (for zoom link and class reminder texts only)

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8. Email for gift cards (Required.)

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9. Insurance Status

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10. Sexual Orientation

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11. Gender Identity

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12. Hispanic, Latino/a, or of Spanish origin?

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13. American Indian or Alaska Native?

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14. Asian

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15. Black or African American

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16. Hispanic or Latino

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17. Middle Eastern or North African

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18. Native Hawaiian or Pacific Islander

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19. White

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20. Primary language? (Enter for example: English , Spanish, or Tagalog, etc.)

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21. Preferred language or what you like to speak?
(Enter for example: English , Spanish, or Tagalog, etc.)

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22. Total Household Members (if you are on your own, you count as 1. Then count your live-in relatives, children etc.)

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i We adjusted the number you entered based on the slider’s scale.

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23. Housing Status

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24. Pregnant or parenting

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25. * Please type the word "youth" to confirm you are not a bot.

Thank you! Press Done below to complete your enrollment!

Please note we meet on Mondays and Wednesdays, 5pm to 6:30 pm, for 4 weeks on Zoom.
We will text or email you the class link and more information closer to the first day of class!

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