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Consent and Information Form
Please fill out this form and submit if you would like to be included in a graphic poster and database, printed and online, that shares information on Indigenous, Black and People of Color mental health workers local to Kjipuktuk / HRM. The poster will be designed by Khyber co-director and visual artist Bria Miller and shared as a community resource as printed resources and a database online. She will update the resource as more names come.

"Knowing there is a huge gap in access to IBPOC mental health workers for IBPOC residents of the HRM, and how difficult it can be to find mental health support in our current existing system, ESPECIALLY for IBPOC individuals, I hope to compile as many mental health workers so that we have an easier to find go-to contact database for who to call when we/our loved ones are having a hard time and need to see someone. I have longed for a resource like this in many situations, and decided to create it instead of waiting for someone else to" - Bria Miller

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I consent to the information in this form being used to advertise my practice in a graphic poster and as part of a community resource database. *
Honorific, name, and pronouns
E.g. Dr. Gillian Green she/her/hers
How do you self-identify in regards to your gender and sexuality?
Address, name and contact information for your office or place of work
Also include phone numbers, emails, website and any social media handles if those exist
Your title or category of practice
Select any and all that apply
Describe your practice *
Frameworks, background and/or roots to your practice as a mental health worker, incl. any credentials or education, or anything that makes your practice unique. Feel free to also elaborate on the information we have available for you to be more accurate if needed.
This poster is being created to share information on Indigenous, Black and/or People of Color mental health workers. Check any identities that you identify with or if you do not identify with these, share how you identify below. *
Required
Share more about yourself here
This can include information on your culture, nations, gender, sexuality, any life experiences and identities that you hold that may inform your practice.
Anything else!
Please include anything else that you would like for us to know or include about you and your practice.
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