The Ariafya Universe wants to better serve you, so we need to hear from you!

We request that interested individuals complete the following questionnaire in order to gain feedback on your perception of the Mental Health Care industry overall and specifically, The Ariafya Universe. Plus, we love to hear your ideas and suggestions to make improvements!

With your feedback, not only will we retain our current interest levels, but we’ll have the feedback to gain new interests leading to full membership, too. Data from this questionnaire will be used to make recommendations for changes within our business.

Your input is very valuable and important to us and it kept in the strictness of confidentiality following HIPAA regulations, except for that required by law. Thank you very much for your time in participating in our questionnaire.

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* 1. Please enter your most recent and accurate information:
Your information will ONLY be shared amongst The Ari | af | ya Universe brands.
Your information will NEVER be shared with 3rd party affiliates

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* 2. What is your preferred contact method?

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* 3. We will be contacting you by email and/or phone. If there are any changes to your health
that you would like to discuss, please list them here. Thanks.

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* 4. (Select all that apply) Which brands of The Ariafya Universe peak your interest?

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* 5. Please add your birthday!

Date

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* 7. (Optional) What is your marital status

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* 8. (Optional) Number of children in the household?

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* 10. (Optional) Racial/Ethnic/Cultural preferred identities?

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* 11. (Select all that apply) Current livelihood situation?

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* 12. (Select all that apply) What are your life's major concerns?

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