Mental Health Survey

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Please fill out the form below and contact Assemblyman Pat Burke's office with any questions

Name *

Email *

Phone Number *

Address *

Occupation *

Gender *

Male

Female

Prefer not to say

Other:

Race/Ethnicity *

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or other Pacific Islander

White

Other:

Have you been affected by the loss of a loved one to suicide?
*

Yes

If yes, what was their relationship to you?
*

Are you willing to participate in focus groups and interviews with the University at Buffalo to better understand the underlying causes of suicide contagion in our community?
*

Yes

Maybe - Would like more information

May we contact you with further information regarding your possible participation in the advisory committee?
*

Yes

Comments, questions, or concerns?

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