HELP RESEARCHERS UNDERSTAND HOW TO IMPROVE MENTAL HEALTH TREATMENT FOR NATIVE HAWAIIAN AND PACIFIC ISLANDER FAMILIES

Who is completing this form?

Caregiver of a child Youth aged 12-15

Choose 'Caregiver of a child' if you are a parent or caregiver of an NHPI child aged 5-15. Choose 'Youth aged 12-15' if you are a NHPI youth completing this for yourself.

What is your name? (first and last)

What is your email address?

What is your phone number? (Please include area code)

Date of Birth

Format: Month/Day/Year (e.g., 01/15/2010)

City and State

How would you prefer that we contact you about the study?

Phone call Text message Email No preference

What are the best days and times for us to reach you?

How old is your child?

What is your child's race and ethnicity? (Select all that apply)

American Indian, Alaska Native, Native American, or Indigenous Asian or Asian American Black or African American Hispanic or Latino/a/e/x Middle Eastern or North African Native Hawaiian or Pacific Islander White or European American None of these describe me

Please specify your child's race or ethnicity:

Has your child received mental health care (such as therapy or counseling)?

Yes No Not sure

Optional — feel free to skip if unsure.

If yes, what was the care for? (Select all that apply)

Anxiety Depression Trauma Conduct Substance use

How old are you?

What is your race and ethnicity? (Select all that apply)

American Indian, Alaska Native, Native American, or Indigenous Asian or Asian American Black or African American Hispanic or Latino/a/e/x Middle Eastern or North African Native Hawaiian or Pacific Islander White or European American None of these describe me

Please specify your race or ethnicity:

Have you received therapy for anxiety, depression, trauma, conduct, or substance use?

Yes No Not sure

Optional — feel free to skip if unsure.

If yes, what was the therapy for? (Select all that apply)

Anxiety Depression Trauma Conduct Substance use

Are you willing to be contacted about future clinical studies?

Yes No

What types of studies would you be interested in?

List comma separated keywords