Name *

First Name

Last Name

Phone *

(###)

###

####

My organization has made this program a priority for me and my time *

Yes

No

I have completed the 8-hour Mental Health First Aid course *

Yes

No

Does your organization have an active CIT or other Crisis response program *

Yes

No

How did you find out about the Detroit-Wayne CIT training program

Employer email

Employer requirement

Professional relationship

Personal relationship

Internet search

Individual who has attended the Detroit-Wayne CIT course

Other

Have you or someone that you love experienced a mental illness or substance use disorder? *

Yes

No

Over the past two weeks, have you experienced little interest or pleasure in doing things? *

Yes

No

Over the past two weeks, have you felt down, depressed, or hopeless? *

Yes

No