Free Minds Interest Form

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The Free Minds Initiative is a program of the San Francisco Human Rights Commission in partnership with the Department of Public Health. It seeks to provide free mental health services to all Black/African American residents of San Francisco. To be added to the applicant pool and receive program updates, please fill out the survey below.

This program is not restricted based on income; anyone is eligible to apply.

Name (first and last) *

Email *

What is your residential zip code? *

Please specify your ethnicity. *

Black or African American

Hispanic or Latino

Native American or American Indian

Asian/Pacific Islander

White

Other

What is your age? *

17 and below

18-24

25-34

35-44

45-54

55-64

65 and over

How did you hear about the Free Minds Initiative? *

Human Rights Commission

Friends/family

Community leader/ community based organization

Social media/ digital marketing

Other:

What is your current employment status? *

Employed for wages

Self-employed

Out of work and looking for work

Out of work but not currently looking for work

Homemaker

Student

Military

Retired

Unable to work

What is your marital status? *

Single, never married

Married or domestic partnership

Widowed

Divorced

Separated

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