Enrollment MM Bootcamp, Cohort 14

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

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* 3. First Name

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* 4. What name would like us to call you?

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* 5. Age Range

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* 6. Year of birth?

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

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* 8. Email for gift cards

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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?

Yes

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* 13. American Indian or Alaska Native?

Yes

(Enter for example: Navajo, Blackfoot, or Nome Eskimo Community, etc.)

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* 14. Asian

Yes

(Enter for example: Chinese, South Asian, and Filipino, etc.)

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* 15. Black or African American

Yes

(Enter for example: Jamaican, Ethiopian, and Somalian, etc.)

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* 16. Hispanic or Latino

Yes

(Enter for example: Mexican, Salvadoran, or Cuban, etc.)

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* 17. Middle Eastern or North African

Yes

(Enter for example: Lebanese, Iraqi or Israeli etc.)

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* 18. Native Hawaiian or Pacific Islander

Yes

(Enter for example: Samoan, Tongan or Tahitian etc.)

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* 19. White

Yes

(Enter for example: Irish, French or Polish etc.)

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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.)

Clear

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

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* 23. Housing Status

Other – such as Treatment or Transitional housing

Unhoused

Housed

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* 24. Pregnant or Expecting Mother

Yes

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!

Enrollment MM Bootcamp, Cohort 14

About You

Question Title

* 1. Name of person who referred you

Question Title

* 2. Last Name

Question Title

* 3. First Name

Question Title

* 4. What name would like us to call you?

Question Title

* 5. Age Range

Question Title

* 6. Year of birth?

Question Title

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

Question Title

* 8. Email for gift cards

Question Title

* 9. Insurance Status

Question Title

* 10. Sexual Orientation

Question Title

* 11. Gender Identity

Question Title

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

Question Title

* 13. American Indian or Alaska Native?

Question Title

* 14. Asian

Question Title

* 15. Black or African American

Question Title

* 16. Hispanic or Latino

Question Title

* 17. Middle Eastern or North African

Question Title

* 18. Native Hawaiian or Pacific Islander

Question Title

* 19. White

Question Title

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

Question Title

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

Question Title

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

Question Title

* 23. Housing Status

Question Title

* 24. Pregnant or Expecting Mother

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