Email address
This form is collecting email addresses.Change settings
Contact Name and Title
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Contact Email
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Contact Phone Number
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
I am filling out this survey on behalf of a...
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
College/University
Government Agency (local, state, or federal)
Hospital, Medical Center or Mental Health Services Provider
Corporation
Other…
Add option
…
Loading...
Host location (City, State)
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Estimated Target Audience (please check all that apply)
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Students
Parents/Families
Employees
Corporate Executives
Mental Health Professionals
Government Officials
First Responders
Faculty/Staff
Open to local community
Other…
Add option
…
Loading...
Estimated Audience Size
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
50-100
101-150
151-200
200+
Add option
or
…
Loading...
Date Option 1
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Date Option 2
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
Date Option 3
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Loading...
How will this event be hosted?
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
We will be using our organization's virtual meeting platform (Zoom, Webex, BlueJean, etc.)
We prefer to use The Quell Foundation's Zoom account
Add option
or
…
Loading...
Will you require attendees to register?
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes. We'll use our organization's registration platform
Yes. We'd prefer to use The Quell Foundation's EventBrite registration account
No. No registration required.
Add option
or
…
Loading...
We've identified a local mental health professional who will be in attendance to support the post-screening discussion.
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Yes
Not yet, but we will
We need help identifying someone
Add option
or
…
Loading...
Please check all that apply
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
We have a designated team/point person to oversee promotion of the event.
We are looking to co-host the screening event with another organization.
We have access to media & public relations outlets.
We have a budget to fund educational/awareness events such as this.
We will likely seek funding to host this event.
This event will be part of a larger campaign/initiative/program at our organization.
Add option
or
…
Loading...
Please upload any logo(s) of the host organization. The Quell Foundation will use to produce branded materials for you to use in promoting the event.
Question
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Multiple choice grid
Checkbox grid
Date
Time
Allow only specific file types
Maximum number of files
1
5
10
Maximum file size
1 MB
10 MB
100 MB
1 GB
10 GB
Loading...
Message for respondents
This form is no longer accepting responses
Summary
Question
Individual
Insights
Total points distribution
Loading...