Whole‑Person Wellness & Support Survey

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Yes, subscribe me to your newsletter.

Which area do you live in or visit most often?

Jonesboro / Clayton County

MLK Corridor / West Atlanta

Midtown / Central Atlanta

Other

Have you ever avoided care because of discomfort, bias, or identity‑related experiences?

Yes

No

Prefer not to say

Would grounding or emotional support before/after appointments help you feel safer?

Yes

Maybe

No

What types of support would help you feel more comfortable during care? (Select all that apply)

Breathing or grounding exercises

Someone to talk to before/after the exam

Someone present during the exam (with consent)

Clear explanations of what to expect

Help managing dysphoria or anxiety

Other

What types of resources or navigation support would be most helpful to you? (Select all that apply)

Are you interested in leadership, advocacy, or community involvement?

Yes

Maybe

No

What are the biggest challenges in your area related to care or support?

What would make you feel safer, more respected, and more supported during healthcare visits?

By submitting this form, I confirm that I am sharing this information voluntarily and understand it will be used to improve community‑centered wellness and support services.

I would like to receive updates about new wellness programs, services, and community initiatives connected to this clinic.