GSP Intake

By completing this Intake form, user acknowledges releasing the use of their photos, videos, testimonials, solicited feedback and surveys acquired by GSP for use in GSP studies and materials which include but not limited to website, media campaigns, and slide decks.

Go to the GSP site

Please complete the following intake form.

Enter your first and last name:(Required)

First Last

Gender: How do you identify yourself?(Required)

Male

Female

Non-binary

Prefer to self-describe, below

Other Gender Identity

Which of the following best describes your current relationship status?(Required)

Married

Widowed

Divorced

Seperated

Single, never married

Cohabitation with significant other or domestic partner

Prefer not to answer

Which of the following best describes you?(Required)

Asian

Black or African American

Middle Eastern or North African

Multiracial or Multiethnic

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

White

Other

Other Race or Ethnicity

Are you Hispanic, Latino, or of Spanish origin or descent?(Required)

Yes

What is your day of birth?(Required)

MM slash DD slash YYYY

What is your highest level of education completed?(Required)

Elementry

High School

College

Master's Degree

PhD

No formal schooling

Throughout the year, GSP may mail you information on upcoming free programs and engagement incentives. Please provide your mailing address to receive this information.

Enter your address:(Required)

Street Address City State ZIP Code

Name of your County?(Required)

What is you phone number?(Required)

What is your email?(Required)

How did you hear about the services and/or programs provided by GSP?(Required)

Community Event (Health Fair, Festival, School Event, Council Meeting, etc.)

Social Media

Word of Mouth

TV, News, and/or Magazine Ad

Referred by an Organization or Individual (please specify who referred you)

Referred by:(Required)

Which service or program are you interested in?(Required)

Soul Synergy: Diabetes Prevention Program (DPP)

Severing Intergenerational Ties with Chronic Illness

Mental Health First Aid (Teen, Youth, and Adult)

Covid-19 education and vaccinations

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