Community Listening Session Registration Question Title * 1. What is your first name? Question Title * 2. What is your last name? Question Title * 3. What is your email address? Question Title * 4. I would like to join the following: September 23, 2025 - ATCAA | Early Childhood Family Listening Session 6:00-7:00pm Question Title * 5. What is your affiliation with Behavioral Health/Public Health? (select all that apply) Family member of youth or adult receiving or eligible for ACBH services Adult or older adult eligible for ACBH behavioral health and/or substance use disorder services Youth living in Amador County Youth mental health or substance use disorder organization Veteran Health care organization, including hospitals Health care service plans, including Medi-Cal managed care plans Disability insurer Public safety partner, including county juvenile justice agencies Area agency on aging Higher education partner (Amador College Connect, etc.) Local education agency or school district Early childhood organization Amador County Public Health Amador County Social Services Independent living center representative Homeless service provider, Continuum of Care representative Provider of mental health services and substance use disorder treatment services Tribal and Indian Health Program representative Emergency medical services Labor representative organizations Community-based organization serving culturally and linguistically diverse community members Regional center representative Other (please specify) None of the above Question Title * 6. What age group are you in? Under 18 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 7. What is your race/ethnicity? (select all that apply) American Indian or Alaska Native Asian or Asian American Black or African American Hispanic or Latino Middle Eastern or North African Native Hawaiian or other Pacific Islander White or Caucasian Question Title * 8. What is your primary language? English Spanish Other (please specify): Question Title * 9. Do you think of yourself as: | Te consideras: Male | Masculino Female | Femenina Transgender Male/Trans Man | Hombre transgénero/Hombre trans Transgender Female/Trans Woman | Mujer transgénero/Mujer trans Nonbinary, neither exclusively male or female | No binario, ni exclusivamente masculino ni femenino Decline to Answer | Negarse a responder Something else, please specify: | Algo más, por favor especifique: Question Title * 10. Do you think of yourself as: | Te consideras: Straight or heterosexual | Heterosexual o heterosexual Lesbian, gay or homosexual | Lesbiana, gay u homosexual Bisexual | Bisexual Don't Know | no lo sé Decline to Answer | Negarse a responder Something else, please specify: | Algo más, por favor especifique: Question Title * 11. What city/town/area do you live in? | ¿En qué ciudad/pueblo/zona vives? Amador City Buckhorn Camanche Fiddletown Ione Jackson Martell Pioneer Pine Grove River Pines Sutter Creek Plymouth Volcano Other (please specify) | Otro (por favor especifique) Done