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Please complete this form as openly and accurately as possible. Video submission instructions will be sent upon completion of this form. Thank you for your interest!
First name
Last name
Phone
Email
List all social media
Relationship Status
*
Single
Engaged/Newyl Wed (3-Years)
Married
Divorced
What is your sexual orientation?
*
Straight
Gay
Bi/Pansexual
Non-Binary
Have you had any prior experience sharing your story or speaking publicly about mental health?
Choose an option
Are you comfortable discussing sensitive topics related to mental health, including potential challenges, traumas, or stigmatized experiences?
Choose an option
In what ways has therapy postively impacted your live?
What is a traumatic experience that you've gone through and have effectively used therapy to aid in your healing journey?
What did you do to cope prior to therapy?
In your opinion, what are some of the barriers or obstacles that prevent Black men from seeking help for mental health concerns?
Do you have any children?
*
Yes
No
Select all that apply.
*
AADD
Anxiety Disorder (Social/General)
Barber
Bipolar Disorder
Christian
Clinical/Moderate Depression
Entrepreneur
Ex-Convict
Health Insurance
High Stress Job
Influencer
Law Enforcement
Mental Health Professional
Obessive Complusive Disorder
Panic Disorder
Phobia
PTSD
Religious
Single Father
Spiritual
U.S. Veteran
In your opinion, how do societal expectations of Black Masculinity affect mental health and the willingness to seek support?
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By checking this box, I agree that if selected I will self film/doucment my life experience as it pertains to this subject for this project. I understand that filming will occur over a 56 day period, with weekly film requirements. I also agree to be truthfull and transparent with my experience.
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