First Name *

Last Name *

Email *

Phone Number *

Employer *

Address Line 1 *

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City *

State/Province * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Zip/Postal Code *

Country United States of America Canada Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia (Plurinational State of) Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (the Democratic Republic of the) Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands [Malvinas] Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (the Democratic People's Republic of) Korea (the Republic of) Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia (the former Yugoslav Republic of) Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia (Federated States of) Moldova (the Republic of) Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan (Province of China) Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela (Bolivarian Republic of) Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara* Yemen Zambia Zimbabwe

About You

Profession * Associates Speech & Language Therapy Psychology Medical or Law Masters / Maestr�a Masters Home Visitor Home Visiting Program High School/GED Doctorate / Doctorado Doctorate Child Development CDA Bachelors / Licenciatura Bachelors Consultant Counselor/Therapist Doula/Midwife Education Family Support Nursing Occupational Therapy Pediatrics Physical Therapy Psychology/Psychiatry Social Work Special Education Speech and Language Therapy Student Other

IMH Role * Occupational Therapist Current Member Supervisor Student Staff/Board/Committee member Speech and Language Therapist Special Educator Social Worker Researcher Public health nurse Physical/occupational/speech therapist Physical Therapist Parent Educator Other Nurse Mental Health Provider Management/Administration Home Visitor Home Visiting Supervisor Educator Early Childhood Educator/Childcare Provider Doula Community Partner or Champion Community Organizer Community Health Worker Child Welfare Staff Member Advocate Service Provider

Region(s) serving (select all that apply) *

Field Employed * Early Care and Education Part C (Early Intervention, ESIT) Public Health Child Welfare Early Care and Education (center-based) Early Care and Education (home-based) Early Intervention (Part C, ESIT) Home Visiting Program Law/Courts Mental Health Pediatrics Policy/Advocacy Pregnancy and Perinatal Support (Doula/Midwife/OBGYN) Retired Teaching/Faculty (college/university level) Other

Field employed: Other (please describe)

Do you directly support families on a weekly basis? *

Do you supervise staff who directly support families? *

Years worked with infants, young children, and families 6 - 10 years Less than 2 years 2 - 5 years 5 - 10 years 10+ years

Highest degree earned * PhD LMHC LMHCA MA MIT MPH MS-MHC Nursing Nursing / Enfermeria Occupational Therapy Other LICSW Physical Therapy Psychology/Psychiatry RN Social Work Social Work / Trabajo Social Special Education Speech & Language Therapy Speech & Language Therapy / Terapia del habla y lenguaje Student / Estudiante LCMHC ABS BA BS BSN Consultant Counselor/Therapist Doula/Midwife Education Education / Educacion Family Support Family Support / Apoyo familiar IMH-E� High school/GED CDA Associates Bachelors Masters Doctorate Medical or Law

Demographic Information

Gender Female Male Non-binary Prefer not to say Prefer to self-describe

Gender (please self-describe, if desired)

Language(s) spoken

Language Preferred American Sign Language Amharic Arabic Chinese (Cantonese) French Mandarin Spanish Vietnamese English

Racial/ethnic background Hispanic, Latin x - regional ancestry not specified Hispanic or Latino Hispanic , Latinx, Central American American Indian or Alaska Native Asian - regional ancestry not specified Central Asian Eastern Asian Southeastern Asian Black - regional ancestry not specified Black - African American Black - African Canadian Black - East African Black - Latin American Black - West African Hispanic, Latinx - regional ancestry not specified Hispanic, Latinx, or Caribbean Hispanic, Latinx, or Central American Hispanic, Latinx, or South American Hispanic, Latinx, or Spanish origin Middle Eastern/North African Native Hawaiian or Pacific Islander White Prefer not to say Prefer to self-describe

Racial/ethnic background (self-describe)

Age range Prefer not to answer 18-24 years old 25-34 years old 35-44 years old 45-54 years old 55-64 years old 65-74 years old 75 years or older

Individual annual income <$10,000 $10,000-$30,000 $30,000-$50,000 $50,000-$70,000 $70,000-$90,000 $90,000+

Live in community served Yes No