Bello : Sarah - The Ross Center

Name of Person interested in the REACH program(Required)

How would the Interested Person describe their race/ethnicity?(Required)

Date of Birth(Required)

How would the Interested Person describe their gender?

What is the potential participant's grade in school or year in college (if applicable)?

What is your occupation (if applicable)?

Phone(Required)

Email(Required)

Region where you will be located during the group (please choose from the list below):(Required)

Please note that participants of the REACH program must be located in the states of New York, Virginia, Washington, DC, or Maryland to participate in this program. The group will be delivered virtually.

Which Group are you (or your child) most interested in? (please choose from the list below)

Does the Interested Person have any prior or current psychiatric diagnosis(es)? If so, please list them below:

Is the Interested Person currently engaged in any psychiatric care (e.g., individual therapy, group therapy, medication management)? If yes, please list the name of the treatment provider and type of treatment:(Required)

Does the Interested Person want to explore and strengthen their love for and pride in their racial/ethnic identity (or any other part of their identity)? (yes/no) If so, please describe why this of interest to them:(Required)

Has the Interested Person experienced, or do they anticipate experiencing, cultural stress because of some part of their identity? (yes/no) If so, please describe which areas of their life that they are experiencing or anticipate experiencing cultural stress:(Required)

Does the Interested Person want to feel more confident in their ability to handle cultural stresses when they happen? (yes/no) If so, please describe how they hope participating in the REACH program will help them cope with:(Required)

How did you hear about The REACH program? If you were referred by a health care provider, please include their name:

Comments

This field is for validation purposes and should be left unchanged.

Sarah Bello

Washington, D.C.

Northern Virginia

New York, NY

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