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I Pledge
to know the Five Signs of emotional suffering and change the culture surrounding
mental health, mental illness, and wellness for my organization/group.
1
Your Organization
2
About You
3
Pledge to ChangeDirection
Describe Your Group/Organization
Business/Organization Name
*
Name of the company, group or organization you represent.
Type of Organization
*
Pick the option below that best describes your organization
Business/Corporate
Church/Faith Community
Government
Health Care
Military
School/University
Nonprofit
Other
Regional Effort
I would like to be part of a regional effort in:
No thanks
Illinois (Chicago metro area)
Indiana
Maryland (Washington DC metro area)
New Hampshire
Ohio (Summit County area)
Pennsylvania (Lancaster County)
Rhode Island
Wisconsin (LaCrosse 7 Rivers area)
Organization/Group Description
*
Provide a brief description of your organization/group.
Military Branch
Choose the military branch below that your organization either serves or supports.
Air Force
Army
Coast Guard
Navy
Marines
Multiple Branches
Active Duty or Veteran?
Thank you for serving our country! Please let us know if you are a veteran or active duty.
Active Duty
Veteran
Other
School/University Type
Indicate the level of education.
K-9
High School
College/University (Four-year)
Community/Jr. College (Two-year)
Government
Choose the branch of the government below.
Federal
State
Local
Website
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
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
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
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 and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
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
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
About You
Name
*
First
Last
Email
*
Enter Email
Confirm Email
We will not share your email address with anyone else.
Phone
Our Pledge to Change Direction
Our Pledge: The Five Signs
*
We agree to share the Five Signs of Emotional Suffering by (check all that apply):
Distributing the Five Signs definitions which can be downloaded on the website
Hanging up the poster in our office or building
Sharing the signs via social media
Writing a blog or article about the signs in our newsletter or for our website
Organizing a brown bag lunch to discuss the signs and the impact on our organization
Sharing the signs at an event
Other (examples shared in next field)
Other ways you plan to share the Five Signs
Please include a list of other ways you plan to share the Five Signs.
Expected Reach?
*
Estimate the number of people in your organization/group who will share the Five Signs of Emotional Suffering with in the next five years.
Please enter a number greater than or equal to
10
.
Our Pledge: how we plan to change direction
In addition to sharing the Five Signs of Emotional Suffering, my organization plans to do the following in order to change the direction of mental health, mental illness, and wellness in America. Feel free to list any specific programs, initiatives, conferences, meetings, events, etc.
Upload Your Files
Upload any program or event information that you wish us to be aware of.
Drop files here or
Accepted file types: jpg, gif, png, pdf, ppt.
Video/Audio/Multimedia URL
If the video/audio recording you've created is publicly accessible on the internet (eg, youtube, vine, slideshare, etc), please share the web address!
Company Logo
If you have access to your company/organization logo, we'd love to display it on our site!
Accepted file types: jpg, gif, png, pdf.
Our Mission
*
Provide your organization or group mission or goals to appear online in addition to your campaign pledge.
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Name
This field is for validation purposes and should be left unchanged.
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