WellbeingMN
Concern Registration
Date: Tuesday 11 Aug, 2020
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Community Member Details:
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Name
*
Address
*
ZIP Code
*
Choose Ethnicity
*
Choose any one
African
African American
American Indian/Alaska Native
Asian/SE Asian/Pacific Islander
Hispanic/Chicano/Latino
Native Hawaian
White/Caucasian
Multiracial
Choose Age Range
*
Choose age range
12-14 Years
15-18 Years
19-24 Years
25-30 Years
31-34 Years
35-40 Years
41-45 Years
46-50 Years
51-55 Years
56-60 Years
61-65 Years
66-70 years
70 and above
Mobile Number
*
10 digit mobile number e.g: 123467890
Gender
Male
Female
Transgender
I speak more than one language
Yes
No
Which one
Spanish
Hmong
Oromo
German
Vietnamese
Chinese
French
Russian
Laotian
Arabic
Amharic
Hindi
Kru, Ibo, Yoruba
Korean
Mon-Khmer, Cambodian
Tagalog
Telugu
Norwegian
Ojibwa
Karen
Swahili
Somali
Sidamo
Other
Please Specify languages separated by a comma (,):
Concern Details:
Concern Category
*
Select Concern Category
Educational Concerns (Personal Concern)
Legal Concerns (Personal Concern)
Social Concerns (Personal Concern)
Marital Concerns
Unemployment
Medical Concerns
Anxiety
Panic Attacks
Trauma
Depression
Substance Abuse
Suicidal Thoughts
Non-suicidal Self-injury
Eating Disorders
Concern Details
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Send Concern to
*
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Imam
Pastor
Community Leader
Others
Choose Spiritual Leader
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Image
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