Name*Req
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Name
or Alias to Use for Story**
(leave blank if you want to use your real, full name)
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Date
of Birth*Req
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/
/
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Gender*Req
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Male
Female |
Affiliation* (optional)
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Address*Req
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Apartment
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City*Req
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State,
ZIP *Req
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Phone
(home)
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Phone
(work)
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E-mail*Req
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Confirm
E-mail*Req
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Ethnicity
(Check all that apply)
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Native American /Alaska Native
Asian American/Pacific Islander
Black/African American
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Hispanic/Latino
White, not of Hispanic/Latino Origin
Other
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Type
of Mental Health Condition* Req
(Check all that apply)
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Anorexia Nervosa
Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD)
Bi-polar Disorder
Bulimia Nervosa
Co-Occurring Disorder/Substance Abuse
Conduct Disorder
Depression
Generalized Anxiety Disorder (GAD)
Obsessive Compulsive Disorder (OCD)
Panic Disorder
Post Traumatic Stress Disorder (PTSD)
Post-partum Depression
Schizophrenia
Seasonal Affective Disorder (SAD)
Self-Injury
Social Anxiety Disorder
Trauma (Sexual/War/Violence/Disaster/Other Assault)
Other:
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Type
of health insurance/care*Req
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Public/Medicaid/Medicare
Private
None |
* Information
is for internal purposes only and will not be made public,
unless permission is granted.
** If
preferred, only your first name and/or alias will be used.
Please indicate if this is the case.
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Please Note:
If you need
help finding treatment, support groups, our local Mental
Health America affiliate, or
other mental health-related services in your community,
please click here to access our Frequently
Asked Questions and Answers. If
you or someone you know is in crisis, please
call your local crisis center or 1-800-273-TALK (8255)
to reach a 24 hour crisis center.
Submit Your Story
Use the box below to submit your
story to Real Lives. While writing your story, keep some
of the questions below in mind to help guide you. You may
not have space to answer them all—and you may have details to add that our questions don’t cover. That is fine!
You may also e-mail us your story
directly to reallives@mentalhealthamerica.net.
Questions to Consider when Writing
Your Story
- How has mental illness affected
your life? Your relationships? Your schoolwork or job?
- Describe your experience
with mental illness. How old were you when your illness
began to affect you? Was there a diagnosis, and if so,
what was it?
- Do you have insurance coverage?
- What form of treatment have
you received? If you haven’t sought care, why not?
- What problems have you encountered
in getting care? Have you been able to get healthcare
and other mental health services when you needed them?
Have you experienced discrimination by an employer, landlord,
health insurance plan, etc.?
- Tell us about other aspects
of your life. For example: What you do for a living or
are you a student? Are you married? Do you have children?
Where do you live? What is your highest level of education?
What are your hobbies or interests?
- What is your life like now?
- If you could change one
thing about how people think about mental illnesses,
what would it be?
- What has been most helpful
to you as you have worked to cope with mental health
problems in your life and manage your illness?
- Is there anything else that
you would like to say?
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