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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. Last Name

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* 2. First Name

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* 3. Preferred name (what you want us to call you:)

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* 4. Age Range

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* 5. Year of birth?

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* 7. Cell Number (For class reminder texts only)

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* 8. Insurance Status

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* 9. Sexual Orientation

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* 10. Gender Identity

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

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* 12. American Indian or Alaska Native?

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* 13. Asian

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* 14. Black or African American

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* 15. Hispanic or Latino

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* 16. Middle Eastern or North African

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* 17. Native Hawaiian or Pacific Islander

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* 18. White

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

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

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

1 20
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i We adjusted the number you entered based on the slider’s scale.

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* 22. Housing Status

Thank you! Press Done below to complete your enrollment!
We meet Tuesdays and Thursdays at 5pm for 6 sessions on Zoom.
We will email and/or text you the class link and more information closer to the first day of class!

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