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* 1. What is your name and position/title?

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* 2. What is the name of your institution/company/organization?

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* 3. With which age population do you work (please check all that apply)?

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* 4. Where is your institution/company/organization located?

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* 5. Approximately how many people would be in your audience for an InterACT New York program?

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* 6. How did you hear about InterACT New York?

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* 7. Please list the top 5 challenges that you would like to address using the InterACT New York modality (please list in order of importance).

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* 8. What is the best way to contact you for follow up? (Please provide a phone and/or email address).

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