Critical mental healthcare for frontline workers
Apply to gain access to a new treatment program for healthcare workers with Covid-based stress & trauma. Space in the program is limited to 20 participants in each state - Utah and Colorado. Priority will be given to applicants with the most need.
Demographics
Which program are you applying for?
*
Colorado
Utah
Name
First Name
Last Name
Email
example@example.com
Cell Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Employer
City of Employment
Role/Job Title
Type of healthcare worker
Type of facility (i.e. inpatient, outpatient, residential, day treatment, long term care, rehab, etc)
Inpatient
Outpatient
Residential
Day Treatment
Long Term Care
Rehabilitation Center
Other
Years employed
Hours per week
Income
What is your annual household income?
Please Select
$20,000 - $49,999
$50,000 - $74,999
$75,000 - $99,999
> $100,000
Screening Questions
Using the scale, indicate how these statements reflect your actions and feelings. 0 = Rarely; 1 = Seldom; 2 = Occasionally; 3 = Sometimes ; 4 = Often; 5 = Very often;
Part one: Personal burnout
Personal burnout is a state of prolonged physical and psychological exhaustion. The following questions are for screening purposes and relate to the amount of burnout you’ve been experiencing lately.
How often do you feel emotionally exhausted?
Always
Often
Sometimes
Seldom
Never/Almost Never
I feel drained and exhausted from “giving” so much.
Rarely
0
1
2
3
4
Very Often
5
0 is Rarely, 5 is Very Often
I am preoccupied with the traumatized stories I have heard.
Rarely
0
1
2
3
4
Very Often
5
0 is Rarely, 5 is Very Often
I feel down after working with those I help.
Rarely
0
1
2
3
4
Very Often
5
0 is Rarely, 5 is Very Often
I feel apathetic about my work.
Rarely
0
1
2
3
4
Very Often
5
0 is Rarely, 5 is Very Often
I have flashbacks connected to my work with clients.
Rarely
0
1
2
3
4
Very Often
5
0 is Rarely, 5 is Very Often
Outside of work I avoid certain situations because they remind me of the experiences of those I work with.
Rarely
0
1
2
3
4
Very Often
5
0 is Rarely, 5 is Very Often
Additional Questionnaire
Do you feel any stigma around seeking help for your mental health?
Yes
No
Would you be comfortable sharing your story with the public?
Yes
No
Do you feel your colleagues would benefit from a program like this?
Yes
No
Do you feel your profession specifically encourages you to take care of your mental health?
Yes
No
What action, if any, have you taken for your mental health in the past? Please elaborate.
Submit
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