JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Register here for the Sept. 21 virtual Congressional Briefing on HR 3073, the "Community Mental Wellness and Resilience Act of 2023"
The briefing will be held from 12 noon to 1:30 pm Eastern Time. You will receive the zoom link for the briefing in the automatic response you get after registering here.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Your first and last name (Please write your name carefully and double check its spelling before moving on to the next question)
*
Your answer
Your email: (Please write your email carefully and double check its accuracy before moving to the next question)
*
Your answer
Do you work for a Member of Congress, Government Agency, Non-Profit, Private, or Civic Organization? (Please check appropriate box)
*
Member of Congress
Federal Government Agency
State Government Agency
Local Government Agency
Regional or Tribal Government Agency
Non-profit Organization
Private Organization
Civic organization
The media/journalism
I do not work for any organization or agency
If you work for a Member of Congress please write down their name and State or House District they represent.
*
Your answer
If you work for a Federal, State, Regional or Tribal, or Local Government department or agency please state the name of the agency and the city and state where it is located.
*
Your answer
If you work for non-profit, private, or civic organization please state the name, city, and state where it is located.
*
Your answer
Please state your position or job title
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of TRIG.
Report Abuse
Forms
