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MHAT Pre-Survey
Pre-Survey
Please complete the following questions
PRIOR
to the start of the training. Your information will be utilized to evaluate the course as an evidence-based intervention in Rhode Island.
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Please enter the first letter of your first name.
For example, if your first name is John, you would enter J:
(Required.)
*
Please enter the first letter of your last name.
For example, if your last name is Doe, you would enter D:
(Required.)
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Please enter the last letter of your first name.
For example, if your first name is John, you would enter N:
(Required.)
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Please enter the last letter of your last name.
For example, if your last name is Doe, you would enter E:
(Required.)
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Please enter the two-digit day of your birth date (01-31).
For example, if your date of birth is December 18, you would enter 18 or if your date of birth is December 2, you would enter 02:
(Required.)
What is your age?
Under 18
18-24
25-34
35-44
45-54
55+
What is your gender?
Female
Male
Transgender
Non-Binary
Prefer not to answer
Other (please specify)
What is your race? (Check as many as apply)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
Prefer not to answer
Other (please specify)
Are you Hispanic or Latino?
No
Yes
Are you of Portuguese ancestry?
No
Yes
What is your sexual identity/identity status?
Heterosexual
Lesbian
Gay
Bisexual
Prefer not to answer
Other (please specify)
Do you provide care or services for someone over 55?
No
Yes
Do you identify as a person with lived experience(mental health or substance use challenges), serious mental illness, or in long-term recovery?
No
Yes
Do you support a family member with lived experience (mental health or substance use challenges), serious mental illness, or in long-term recovery?
No
Yes
Are you a veteran or someone caring for a veteran?
No
Yes
Are you an employee of a municipal government in Barrington, Bristol, East Providence, or Warren?
No
Yes
Are you a caregiver of a child with special needs (ie. IEP, 504 plan, learning differences, etc.)?
No
Yes
Where do you live?
Barrington
Bristol
Warren
East Providence
In Rhode Island, outside of Barrington, Bristol, Warren & East Providence
Out of State
Where is the organization or job that you work for located?
Barrington
Bristol
Warren
East Providence
In Rhode Island, outside of Barrington, Bristol, Warren & East Providence
Out of State
Not Applicable
Which of the following mental health or related workforce category BEST describes you?
Mental Health Professionals (e.g., Licensed social worker or counselor, guidance counselor, school psychologist, behavioral health support, etc.)
Health Professionals (e.g., Occupational or physical therapist, school nurse, speech pathologist, primary care provider, etc.)
Family/Student Support (e.g., Case worker or manager, community outreach worker, pupil personnel worker, crisis care worker, etc.)
Tribal (e.g., Healer, elder, elected tribal official)
Law Enforcement (e.g., Probation officer, police officer, SRO)
First Responders (e.g., Firefighters, EMS)
Educator (e.g., School admin, teacher/professor, librarian, paraeducator, early intervention specialist, student, etc.)
Support Staff (e.g., Custodian, cafeteria attendant, bus driver, before and/or after care staff, volunteer, monitor, etc.)
Administrative & Clerical (e.g., Administrative assistant, secretary, registrar, evaluator, etc.)
Other, please specify:
Where do you anticipate using the content from this workshop most directly? (Check all that apply)
Family
Work with colleagues/employees
Work with clients/patients/customers
School - as a peer
School - as an instructor/administrator/staff member
Community groups
Other, please specify:
Are you attending this program as part of a specific grant or program (i.e., MHAT, FRSAN, SOR)?
No
Yes