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Enrollment MM Bootcamp, Cohort 16
About You
Welcome to Mind Matters!
Most of these questions are optional (except the ones with*) and your information will only be shared anonymously.
1.
Name of person who referred you
*
2.
Last Name
(Required.)
*
3.
First Name
(Required.)
4.
What name would like us to call you?
*
5.
Age Range
(Required.)
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27 and older
*
6.
Year of birth?
(Required.)
Over 27 n/a
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
7.
*Cell Number (for zoom link and class reminder texts only)
*
8.
Email for gift cards
(Required.)
9.
Insurance Status
Medi-Cal
Covered CA
No Insurance
Private Insurance
Veterans Benefits
My Health LA
Don't know
10.
Sexual Orientation
Lesbian/Gay
Straight
Bisexual
Same Gender Loving
Asexual
Pansexual
Don't Know
Prefer Not To Answer
11.
Gender Identity
Woman/girl
Man/boy
Two-spirit
Transgender woman/girl
Transgender Man/boy
Genderqueer
Nonbinary
Don't Know
Prefer Not To Answer
12.
Hispanic, Latino/a, or of Spanish origin?
Yes
No
13.
American Indian or Alaska Native?
Yes
No
(Enter for example: Navajo, Blackfoot, or Nome Eskimo Community, etc.)
14.
Asian
Yes
No
(Enter for example: Chinese, South Asian, and Filipino, etc.)
15.
Black or African American
Yes
No
(Enter for example: Jamaican, Ethiopian, and Somalian, etc.)
16.
Hispanic or Latino
Yes
No
(Enter for example: Mexican, Salvadoran, or Cuban, etc.)
17.
Middle Eastern or North African
Yes
No
(Enter for example: Lebanese, Iraqi or Israeli etc.)
18.
Native Hawaiian or Pacific Islander
Yes
No
(Enter for example: Samoan, Tongan or Tahitian etc.)
19.
White
Yes
No
(Enter for example: Irish, French or Polish etc.)
20.
Primary language? (Enter for example: English , Spanish, or Tagalog, etc.)
21.
Preferred language or what you like to speak?
(Enter for example: English , Spanish, or Tagalog, etc.)
22.
Total Household Members (if you are on your own, you count as 1. Then count your live-in relatives, children etc.)
1
20
Clear
23.
Housing Status
Other – such as Treatment or Transitional housing
Unhoused
Housed
24.
Pregnant or parenting
Yes
No
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!
