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Section 2 of 2
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College/University
Government Agency (local, state, or federal)
Hospital, Medical Center or Mental Health Services Provider
Corporation
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Students
Parents/Families
Employees
Corporate Executives
Mental Health Professionals
Government Officials
First Responders
Faculty/Staff
Open to local community
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50-100
101-150
151-200
200+
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We will be using our organization's virtual meeting platform (Zoom, Webex, BlueJean, etc.)
We prefer to use The Quell Foundation's Zoom account
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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.
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Yes
Not yet, but we will
We need help identifying someone
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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.
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Contact Name and Title
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Contact Email
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Contact Phone Number
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I am filling out this survey on behalf of a...
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Host location (City, State)
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Estimated Target Audience (please check all that apply)
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Estimated Audience Size
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Date Option 1
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Date Option 2
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Date Option 3
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How will this event be hosted?
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Will you require attendees to register?
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We've identified a local mental health professional who will be in attendance to support the post-screening discussion.
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Please check all that apply
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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.
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