HearMe20 Participant Form

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We are here to support you in your health journey! Thank you for trusting us to do just that.

Tell us briefly about yourself to help us adequately prepare for you. The information you share will be kept private and only shared with your health professional. You will be meeting with the health professional for 20 minutes to discuss your health issues, so try and be clear and direct with your health questions below.

First name *

Last name *

How old are you? *

18-28 years

29-39 years

40-50 years

51-60 years

Above 60 years

What is your gender?

Female

Male

Non-binary (not male or female)

I prefer to not state

Other:

How do you identify in regards to race and ethnicity (check all that apply) *

African American

Black Immigrant

Black Refugee

Mixed Race

Hispanic/Latine

Other

Required

What is the highest level of education you have attained? *

High School diploma or equivalent

Associate's degree

Bachelor's degree

Master's degree

Doctorate degree

Technical certificate

Other:

Which of these describes your annual household income last year? *

Less than $10,000

$10,000 to $19,999

$20,000 to $29,999

$30,000 to $39,999

$40,000 to $49,999

$50,000 to $59,999

$60,000 to $69,999

$70,000 to $79,999

$80,000 to $89,999

$90,000 to $99,999

$100,000 to $149,99

$150,000 or more

I am not sure

In which Colorado county do you currently live? *

With regards to language, check all that apply

I speak English

I speak another primary language

I would need an interpreter

Other:

Required

Do you have a primary care provider?

Yes

Clear selection

What type of health insurance do you have? This question is for information purposes only. The HearMe20 program is FREE to you.

No health insurance

Private health insurance

Health insurance through an employer

Medicaid/Medicare

Other:

Clear selection

Best phone number to reach you with more information if needed (XXX-XXX-XXXX) *

Best e-mail address to reach you with more information if needed *

Clear form

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