<%@ Language=VBScript %> <% 'form.html 'Created Date: 04/15/2009 'Modification History: 'Updated by ISTCHQS 08/27/2010 to add custom theme to Google ReCaptcha 'File Purpose: Enables user to submit survey form to Colleen Garrahan. 'Updated By ISADRPN 01/22/2010 to add Google Recaptcha ' 1. Line 517 - 550 declares, initializes and tests the IsGoodCaptcha variable ' 2. Block Line 825 - 829 ends conditional if-then test block ' 3. Block Line 845 - 846 Focus cursor on Recaptcha input box upon error ' 4. Block 1681 - instructs user to enter Recaptcha text for security reasons ' 5. Block Line 1684 - 1694 displays the Recaptcha form for input. %> <% Response.Buffer = True Dim strSelected strSelected = " selected=""selected"" " Dim strChecked strChecked = " checked=""checked"" " Dim strFirst Dim strLast Dim strTitle Dim strOrganization Dim strCounty Dim strAddress Dim strCity Dim strState Dim strZip Dim strEmail Dim strPhone Dim strBoard Dim strService Dim strFamily Dim strBoardtwo Dim strServicetwo Dim strFamilytwo Dim strAone Dim strBone Dim strCone Dim strDone Dim strEone Dim strFone Dim strGone Dim strHone Dim strIone Dim strJone Dim strKone Dim strLone Dim strMone Dim strNone Dim strOone Dim strPone Dim strQone Dim strRone Dim strSone Dim strTone Dim strUone Dim strVone Dim strWone Dim strXone Dim strYone Dim strZone Dim strAAone Dim strABone Dim strACone Dim strADone Dim strAEone Dim strAFone Dim strAGone Dim strAHone Dim strAIone Dim strAJone Dim strAKone Dim strALone Dim strAMone Dim strANone Dim strAOone Dim strAPone Dim strAQone Dim strARone Dim strASone Dim strATone Dim strAUone Dim strAVone Dim strAWone Dim strAXone Dim strAYone Dim strAZone Dim strAAAone Dim strAABone Dim strAACone Dim strAADone Dim strAAEone Dim strAAFone Dim strAAGone Dim strAAHone Dim strAAIone Dim strAAJone Dim strAAKone Dim strAALone Dim strAAMone Dim strAANone Dim strAAOone Dim strAAPone Dim strAAQone Dim strAARone Dim strAASone Dim strAATone Dim strAAUone Dim strAAVone Dim strAAWone Dim strAAXone Dim strAAYone Dim strAAZone Dim strAtwo Dim strBtwo Dim strCtwo Dim strDtwo Dim strEtwo Dim strFtwo Dim strGtwo Dim strHtwo Dim strItwo Dim strJtwo Dim strKtwo Dim strLtwo Dim strMtwo Dim strNtwo Dim strOtwo Dim strPtwo Dim strQtwo Dim strRtwo Dim strStwo Dim strTtwo Dim strUtwo Dim strVtwo Dim strWtwo Dim strXtwo Dim strYtwo Dim strZtwo Dim strAAtwo Dim strABtwo Dim strACtwo Dim strADtwo Dim strAEtwo Dim strAFtwo Dim strAGtwo Dim strAHtwo Dim strAItwo Dim strAJtwo Dim strAKtwo Dim strALtwo Dim strAMtwo Dim strANtwo Dim strAOtwo Dim strAPtwo Dim strAQtwo Dim strARtwo Dim strAStwo Dim strATtwo Dim strAUtwo Dim strAVtwo Dim strAWtwo Dim strAXtwo Dim strAYtwo Dim strAZtwo Dim strAAAtwo Dim strAABtwo Dim strAACtwo Dim strAADtwo Dim strAAEtwo Dim strAAFtwo Dim strAAGtwo Dim strAAHtwo Dim strAAItwo Dim strAAJtwo Dim strAAKtwo Dim strAALtwo Dim strAAMtwo Dim strAANtwo Dim strAAOtwo Dim strAAPtwo Dim strAAQtwo Dim strAARtwo Dim strAAStwo Dim strAATtwo Dim strAAUtwo Dim strAAVtwo Dim strAAWtwo Dim strAAXtwo Dim strAAYtwo Dim strAAZtwo Dim strAthree Dim strBthree Dim strCthree Dim strDthree Dim strEthree Dim strFthree Dim strGthree Dim strHthree Dim strIthree Dim strJthree Dim strKthree Dim strLthree Dim strMthree Dim strNthree Dim strOthree Dim strPthree Dim strQthree Dim strRthree Dim strSthree Dim strTthree Dim strUthree Dim strVthree Dim strWthree Dim strXthree Dim strYthree Dim strZthree Dim strAAthree Dim strABthree Dim strACthree Dim strADthree Dim strAEthree Dim strAFthree Dim strAGthree Dim strAHthree Dim strAIthree Dim strAJthree Dim strAKthree Dim strALthree Dim strAMthree Dim strANthree Dim strAOthree Dim strAPthree Dim strAQthree Dim strARthree Dim strASthree Dim strATthree Dim strAUthree Dim strAVthree Dim strAWthree Dim strAXthree Dim strAYthree Dim strAZthree Dim strAAAthree Dim strAABthree Dim strAACthree Dim strAADthree Dim strAAEthree Dim strAAFthree Dim strAAGthree Dim strAAHthree Dim strAAIthree Dim strAAJthree Dim strAAKthree Dim strAALthree Dim strAAMthree Dim strAANthree Dim strAAOthree Dim strAAPthree Dim strAAQthree Dim strAARthree Dim strAASthree Dim strAATthree Dim strAAUthree Dim strAAVthree Dim strAAWthree Dim strAAXthree Dim strAAYthree Dim strAAZthree strFirst = Trim(Request.Form("txtFirst")) 'strLast = Trim(Request.Form("txtLast")) strTitle = Trim(Request.Form("txtTitle")) strOrganization = Trim(Request.Form("txtOrganization")) strCounty = Trim(Request.Form("ddCounty")) strAddress = Trim(Request.Form("txtAddress")) strCity = Trim(Request.Form("txtCity")) strState = Trim(Request.Form("ddState")) strZip = Trim(Request.Form("txtZip")) strEmail = Trim(Request.Form("txtEmail")) strPhone = Trim(Request.Form("txtPhone")) strBoard = Trim(Request.Form("ckbBoard")) strService = Trim(Request.Form("ckbService")) strFamily = Trim(Request.Form("ckbFamily")) strBoardtwo = Trim(Request.Form("ckbBoardtwo")) strServicetwo = Trim(Request.Form("ckbServicetwo")) strFamilytwo = Trim(Request.Form("ckbFamilytwo")) strAone = Trim(Request.Form("ckbAone")) strBone = Trim(Request.Form("ckbBone")) strCone = Trim(Request.Form("ckbCone")) strDone = Trim(Request.Form("ckbDone")) strEone = Trim(Request.Form("ckbEone")) strFone = Trim(Request.Form("ckbFone")) strGone = Trim(Request.Form("ckbGone")) strHone = Trim(Request.Form("ckbHone")) strIone = Trim(Request.Form("ckbIone")) strJone = Trim(Request.Form("ckbJone")) strKone = Trim(Request.Form("ckbKone")) strLone = Trim(Request.Form("ckbLone")) strMone = Trim(Request.Form("ckbMone")) strNone = Trim(Request.Form("ckbNone")) strOone = Trim(Request.Form("ckbOone")) strPone = Trim(Request.Form("ckbPone")) strQone = Trim(Request.Form("ckbQone")) strRone = Trim(Request.Form("ckbRone")) strSone = Trim(Request.Form("ckbSone")) strTone = Trim(Request.Form("ckbTone")) strUone = Trim(Request.Form("ckbUone")) strVone = Trim(Request.Form("ckbVone")) strWone = Trim(Request.Form("ckbWone")) strXone = Trim(Request.Form("ckbXone")) strYone = Trim(Request.Form("ckbYone")) strZone = Trim(Request.Form("ckbZone")) strAAone = Trim(Request.Form("ckbAAone")) strABone = Trim(Request.Form("ckbABone")) strACone = Trim(Request.Form("ckbACone")) strADone = Trim(Request.Form("ckbADone")) strAEone = Trim(Request.Form("ckbAEone")) strAFone = Trim(Request.Form("ckbAFone")) strAGone = Trim(Request.Form("ckbAGone")) strAHone = Trim(Request.Form("ckbAHone")) strAIone = Trim(Request.Form("ckbAIone")) strAJone = Trim(Request.Form("ckbAJone")) strAKone = Trim(Request.Form("ckbAKone")) strALone = Trim(Request.Form("ckbALone")) strAMone = Trim(Request.Form("ckbAMone")) strANone = Trim(Request.Form("ckbANone")) strAOone = Trim(Request.Form("ckbAOone")) strAPone = Trim(Request.Form("ckbAPone")) strAQone = Trim(Request.Form("ckbAQone")) strARone = Trim(Request.Form("ckbARone")) strASone = Trim(Request.Form("ckbASone")) strATone = Trim(Request.Form("ckbATone")) strAUone = Trim(Request.Form("ckbAUone")) strAVone = Trim(Request.Form("ckbAVone")) strAWone = Trim(Request.Form("ckbAWone")) strAXone = Trim(Request.Form("ckbAXone")) strAYone = Trim(Request.Form("ckbAYone")) strAZone = Trim(Request.Form("ckbAZone")) strAAAone = Trim(Request.Form("ckbAAAone")) strAABone = Trim(Request.Form("ckbAABone")) strAACone = Trim(Request.Form("ckbAACone")) strAADone = Trim(Request.Form("ckbAADone")) strAAEone = Trim(Request.Form("ckbAAEone")) strAAFone = Trim(Request.Form("ckbAAFone")) strAAGone = Trim(Request.Form("ckbAAGone")) strAAHone = Trim(Request.Form("ckbAAHone")) strAAIone = Trim(Request.Form("ckbAAIone")) strAAJone = Trim(Request.Form("ckbAAJone")) strAAKone = Trim(Request.Form("ckbAAKone")) strAALone = Trim(Request.Form("ckbAALone")) strAAMone = Trim(Request.Form("ckbAAMone")) strAANone = Trim(Request.Form("ckbAANone")) strAAOone = Trim(Request.Form("ckbAAOone")) strAAPone = Trim(Request.Form("ckbAAPone")) strAAQone = Trim(Request.Form("ckbAAQone")) strAARone = Trim(Request.Form("ckbAARone")) strAASone = Trim(Request.Form("ckbAASone")) strAATone = Trim(Request.Form("ckbAATone")) strAAUone = Trim(Request.Form("ckbAAUone")) strAAVone = Trim(Request.Form("ckbAAVone")) strAAWone = Trim(Request.Form("ckbAAWone")) strAAXone = Trim(Request.Form("ckbAAXone")) strAAYone = Trim(Request.Form("ckbAAYone")) strAAZone = Trim(Request.Form("ckbAAZone")) strAtwo = Trim(Request.Form("ckbAtwo")) strBtwo = Trim(Request.Form("ckbBtwo")) strCtwo = Trim(Request.Form("ckbCtwo")) strDtwo = Trim(Request.Form("ckbDtwo")) strEtwo = Trim(Request.Form("ckbEtwo")) strFtwo = Trim(Request.Form("ckbFtwo")) strGtwo = Trim(Request.Form("ckbGtwo")) strHtwo = Trim(Request.Form("ckbHtwo")) strItwo = Trim(Request.Form("ckbItwo")) strJtwo = Trim(Request.Form("ckbJtwo")) strKtwo = Trim(Request.Form("ckbKtwo")) strLtwo = Trim(Request.Form("ckbLtwo")) strMtwo = Trim(Request.Form("ckbMtwo")) strNtwo = Trim(Request.Form("ckbNtwo")) strOtwo = Trim(Request.Form("ckbOtwo")) strPtwo = Trim(Request.Form("ckbPtwo")) strQtwo = Trim(Request.Form("ckbQtwo")) strRtwo = Trim(Request.Form("ckbRtwo")) strStwo = Trim(Request.Form("ckbStwo")) strTtwo = Trim(Request.Form("ckbTtwo")) strUtwo = Trim(Request.Form("ckbUtwo")) strVtwo = Trim(Request.Form("ckbVtwo")) strWtwo = Trim(Request.Form("ckbWtwo")) strXtwo = Trim(Request.Form("ckbXtwo")) strYtwo = Trim(Request.Form("ckbYtwo")) strZtwo = Trim(Request.Form("ckbZtwo")) strAAtwo = Trim(Request.Form("ckbAAtwo")) strABtwo = Trim(Request.Form("ckbABtwo")) strACtwo = Trim(Request.Form("ckbACtwo")) strADtwo = Trim(Request.Form("ckbADtwo")) strAEtwo = Trim(Request.Form("ckbAEtwo")) strAFtwo = Trim(Request.Form("ckbAFtwo")) strAGtwo = Trim(Request.Form("ckbAGtwo")) strAHtwo = Trim(Request.Form("ckbAHtwo")) strAItwo = Trim(Request.Form("ckbAItwo")) strAJtwo = Trim(Request.Form("ckbAJtwo")) strAKtwo = Trim(Request.Form("ckbAKtwo")) strALtwo = Trim(Request.Form("ckbALtwo")) strAMtwo = Trim(Request.Form("ckbAMtwo")) strANtwo = Trim(Request.Form("ckbANtwo")) strAOtwo = Trim(Request.Form("ckbAOtwo")) strAPtwo = Trim(Request.Form("ckbAPtwo")) strAQtwo = Trim(Request.Form("ckbAQtwo")) strARtwo = Trim(Request.Form("ckbARtwo")) strAStwo = Trim(Request.Form("ckbAStwo")) strATtwo = Trim(Request.Form("ckbATtwo")) strAUtwo = Trim(Request.Form("ckbAUtwo")) strAVtwo = Trim(Request.Form("ckbAVtwo")) strAWtwo = Trim(Request.Form("ckbAWtwo")) strAXtwo = Trim(Request.Form("ckbAXtwo")) strAYtwo = Trim(Request.Form("ckbAYtwo")) strAZtwo = Trim(Request.Form("ckbAZtwo")) strAAAtwo = Trim(Request.Form("ckbAAAtwo")) strAABtwo = Trim(Request.Form("ckbAABtwo")) strAACtwo = Trim(Request.Form("ckbAACtwo")) strAADtwo = Trim(Request.Form("ckbAADtwo")) strAAEtwo = Trim(Request.Form("ckbAAEtwo")) strAAFtwo = Trim(Request.Form("ckbAAFtwo")) strAAGtwo = Trim(Request.Form("ckbAAGtwo")) strAAHtwo = Trim(Request.Form("ckbAAHtwo")) strAAItwo = Trim(Request.Form("ckbAAItwo")) strAAJtwo = Trim(Request.Form("ckbAAJtwo")) strAAKtwo = Trim(Request.Form("ckbAAKtwo")) strAALtwo = Trim(Request.Form("ckbAALtwo")) strAAMtwo = Trim(Request.Form("ckbAAMtwo")) strAANtwo = Trim(Request.Form("ckbAANtwo")) strAAOtwo = Trim(Request.Form("ckbAAOtwo")) strAAPtwo = Trim(Request.Form("ckbAAPtwo")) strAAQtwo = Trim(Request.Form("ckbAAQtwo")) strAARtwo = Trim(Request.Form("ckbAARtwo")) strAAStwo = Trim(Request.Form("ckbAAStwo")) strAATtwo = Trim(Request.Form("ckbAATtwo")) strAAUtwo = Trim(Request.Form("ckbAAUtwo")) strAAVtwo = Trim(Request.Form("ckbAAVtwo")) strAAWtwo = Trim(Request.Form("ckbAAWtwo")) strAAXtwo = Trim(Request.Form("ckbAAXtwo")) strAAYtwo = Trim(Request.Form("ckbAAYtwo")) strAAZtwo = Trim(Request.Form("ckbAAZtwo")) strAthree = Trim(Request.Form("ckbAthree")) strBthree = Trim(Request.Form("ckbBthree")) strCthree = Trim(Request.Form("ckbCthree")) strDthree = Trim(Request.Form("ckbDthree")) strEthree = Trim(Request.Form("ckbEthree")) strFthree = Trim(Request.Form("ckbFthree")) strGthree = Trim(Request.Form("ckbGthree")) strHthree = Trim(Request.Form("ckbHthree")) strIthree = Trim(Request.Form("ckbIthree")) strJthree = Trim(Request.Form("ckbJthree")) strKthree = Trim(Request.Form("ckbKthree")) strLthree = Trim(Request.Form("ckbLthree")) strMthree = Trim(Request.Form("ckbMthree")) strNthree = Trim(Request.Form("ckbNthree")) strOthree = Trim(Request.Form("ckbOthree")) strPthree = Trim(Request.Form("ckbPthree")) strQthree = Trim(Request.Form("ckbQthree")) strRthree = Trim(Request.Form("ckbRthree")) strSthree = Trim(Request.Form("ckbSthree")) strTthree = Trim(Request.Form("ckbTthree")) strUthree = Trim(Request.Form("ckbUthree")) strVthree = Trim(Request.Form("ckbVthree")) strWthree = Trim(Request.Form("ckbWthree")) strXthree = Trim(Request.Form("ckbXthree")) strYthree = Trim(Request.Form("ckbYthree")) strZthree = Trim(Request.Form("ckbZthree")) strAAthree = Trim(Request.Form("ckbAAthree")) strABthree = Trim(Request.Form("ckbABthree")) strACthree = Trim(Request.Form("ckbACthree")) strADthree = Trim(Request.Form("ckbADthree")) strAEthree = Trim(Request.Form("ckbAEthree")) strAFthree = Trim(Request.Form("ckbAFthree")) strAGthree = Trim(Request.Form("ckbAGthree")) strAHthree = Trim(Request.Form("ckbAHthree")) strAIthree = Trim(Request.Form("ckbAIthree")) strAJthree = Trim(Request.Form("ckbAJthree")) strAKthree = Trim(Request.Form("ckbAKthree")) strALthree = Trim(Request.Form("ckbALthree")) strAMthree = Trim(Request.Form("ckbAMthree")) strANthree = Trim(Request.Form("ckbANthree")) strAOthree = Trim(Request.Form("ckbAOthree")) strAPthree = Trim(Request.Form("ckbAPthree")) strAQthree = Trim(Request.Form("ckbAQthree")) strARthree = Trim(Request.Form("ckbARthree")) strASthree = Trim(Request.Form("ckbASthree")) strATthree = Trim(Request.Form("ckbATthree")) strAUthree = Trim(Request.Form("ckbAUthree")) strAVthree = Trim(Request.Form("ckbAVthree")) strAWthree = Trim(Request.Form("ckbAWthree")) strAXthree = Trim(Request.Form("ckbAXthree")) strAYthree = Trim(Request.Form("ckbAYthree")) strAZthree = Trim(Request.Form("ckbAZthree")) strAAAthree = Trim(Request.Form("ckbAAAthree")) strAABthree = Trim(Request.Form("ckbAABthree")) strAACthree = Trim(Request.Form("ckbAACthree")) strAADthree = Trim(Request.Form("ckbAADthree")) strAAEthree = Trim(Request.Form("ckbAAEthree")) strAAFthree = Trim(Request.Form("ckbAAFthree")) strAAGthree = Trim(Request.Form("ckbAAGthree")) strAAHthree = Trim(Request.Form("ckbAAHthree")) strAAIthree = Trim(Request.Form("ckbAAIthree")) strAAJthree = Trim(Request.Form("ckbAAJthree")) strAAKthree = Trim(Request.Form("ckbAAKthree")) strAALthree = Trim(Request.Form("ckbAALthree")) strAAMthree = Trim(Request.Form("ckbAAMthree")) strAANthree = Trim(Request.Form("ckbAANthree")) strAAOthree = Trim(Request.Form("ckbAAOthree")) strAAPthree = Trim(Request.Form("ckbAAPthree")) strAAQthree = Trim(Request.Form("ckbAAQthree")) strAARthree = Trim(Request.Form("ckbAARthree")) strAASthree = Trim(Request.Form("ckbAASthree")) strAATthree = Trim(Request.Form("ckbAATthree")) strAAUthree = Trim(Request.Form("ckbAAUthree")) strAAVthree = Trim(Request.Form("ckbAAVthree")) strAAWthree = Trim(Request.Form("ckbAAWthree")) strAAXthree = Trim(Request.Form("ckbAAXthree")) strAAYthree = Trim(Request.Form("ckbAAYthree")) strAAZthree = Trim(Request.Form("ckbAAZthree")) ' Test the captcha field Dim IsGoodCaptcha IsGoodCaptcha = True If Request.Form("txtPostBack") = "Yes" Then ' This is a Post Back of the registration form. strLast = Trim(Request.Form("txtLast")) ' Test the captcha field Dim strCaptchaError Dim privateKey privateKey = "6LdXFQkAAAAAAFUm3Ry0zlzfBTPP8IAaYgsP6NzK" Dim VarString VarString = _ "privatekey=" & privateKey & _ "&remoteip=" & Request.ServerVariables("REMOTE_ADDR") & _ "&challenge=" & Request.Form("recaptcha_challenge_field") & _ "&response=" & Request.Form("recaptcha_response_field") Dim objXmlHttp Set objXmlHttp = Server.CreateObject("Msxml2.ServerXMLHTTP") objXmlHttp.open "POST", "http://api-verify.recaptcha.net/verify",False objXmlHttp.setRequestHeader "Content-Type","application/x-www-form-urlencoded" objXmlHttp.send VarString Dim ResponseString ResponseString = split(objXmlHttp.responseText,vblf) Set objXmlHttp = Nothing if ResponseString(0) = "true" then ' User answered reCAPTCHA correctly - do input validation. IsGoodCaptcha = True strCaptchaError = "" ' End Recaptcha ' Server side input validation Dim strErrMsgHTML Dim intLenErrMsgHTML ' First Name If strFirst = "" Then strErrMsgHTML = strErrMsgHTML & "Please enter your first name.
" End If ' Last Name If strLast = "" Then strErrMsgHTML = strErrMsgHTML & "Please enter your last name.
" End If ' Organization If strOrganization = "" Then strErrMsgHTML = strErrMsgHTML & "Please enter an organization.
" End If ' County If strCounty = "**" Then strErrMsgHTML = strErrMsgHTML & "Please select a county.
" End If ' Address If strAddress = "" Then strErrMsgHTML = strErrMsgHTML & "Please enter an address.
" End If ' City If strCity = "" Then strErrMsgHTML = strErrMsgHTML & "Please enter a city.
" End If ' State If strState = "**" Then strErrMsgHTML = strErrMsgHTML & "Please select a state.
" End If ' Zip If strZip = "" Then strErrMsgHTML = strErrMsgHTML & "Please enter a zip code.
" End If ' Email If strEmail = "" Then strErrMsgHTML = strErrMsgHTML & "Please enter an e-mail address.
" ''ElseIf (Instr(1,strEmail,"@") = 0) Or (Instr(1,strEmail,".") = 0) Then Else Set objRegExp = New RegExp 'Create the RegExp object objRegExp.Pattern = "\w+([-+.']\w+)*@\w+([-.]\w+)*\.\w+([-.]\w+)*" objRegExp.IgnoreCase = True If objRegExp.Test(strEmail) = False Then strErrMsgHTML = strErrMsgHTML & "Please enter a valid e-mail address.
" End If End If intLenErrMsgHTML = Len(strErrMsgHTML) If intLenErrMsgHTML = 0 Then Dim strMessageBody ' E-mail message body text with the user's responses to items on the form. strMessageBody = "Name:" & vbCrLf & _ vbTab & strFirst & " " & strLast & vbCrLf & _ "Organization:" & vbCrLf & _ vbTab & strOrganization & vbCrLf & _ "County:" & vbCrLf & _ vbTab & strCounty & vbCrLf & _ "Address:" & vbCrLf & _ vbTab & strAddress& vbCrLf & _ "City:" & vbCrLf & _ vbTab & strCity & vbCrLf & _ "State:" & vbCrLf & _ vbTab & strState & vbCrLf & _ "Zip:" & vbCrLf & _ vbTab & strZip & vbCrLf & _ "Phone:" & vbCrLf & _ vbTab & strPhone & vbCrLf & _ "Email:" & vbCrLf & _ vbTab & strEmail & vbCrLf & _ "Would you be willing to serve on Boards or Committees?" & vbCrLf & _ vbTab & strBoard & vbTab & strBoardtwo & vbCrLf & _ "Do you self-identify as someone who has used mental health services?" & vbCrLf & _ vbTab & strService & vbTab & strServicetwo & vbCrLf & _ "Do you self-identify as a family member of someone who has used services?" & vbCrLf & _ vbTab & strFamily & vbTab & strFamilytwo & vbCrLf & _ vbCrLf & _ "***** Clinical Issues *****" & vbCrLf & _ vbCrLf & _ "Advanced Directives: " & vbCrLf & _ vbTab & strAone & vbTab & strAtwo & vbTab & strAthree & vbCrLf & _ "Child Welfare: " & vbCrLf & _ vbTab & strBone & vbTab & strBtwo & vbTab & strBthree & vbCrLf & _ "Civil Commitment: " & vbCrLf & _ vbTab & strCone & vbTab & strCtwo & vbTab & strCthree & vbCrLf & _ "Cultural Competence: " & vbCrLf & _ vbTab & strDone & vbTab & strDtwo & vbTab & strDthree & vbCrLf & _ "Disaster Response: " & vbCrLf & _ vbTab & strEone & vbTab & strEtwo & vbTab & strEthree & vbCrLf & _ "Electroconvulsive Therapy (ECT):" & vbCrLf & _ vbTab & strFone & vbTab & strFtwo & vbTab & strFthree & vbCrLf & _ "Education:" & vbCrLf & _ vbTab & strGone & vbTab & strGtwo & vbTab & strGthree & vbCrLf & _ "Elder Issues:" & vbCrLf & _ vbTab & strHone & vbTab & strHtwo & vbTab & strHthree & vbCrLf & _ "Employment:" & vbCrLf & _ vbTab & strIone & vbTab & strItwo & vbTab & strIthree & vbCrLf & _ "Forced Medication:" & vbCrLf & _ vbTab & strJone & vbTab & strJtwo & vbTab & strJthree & vbCrLf & _ "Forensic:" & vbCrLf & _ vbTab & strKone & vbTab & strKtwo & vbTab & strKthree & vbCrLf & _ "Gay/Lesbian/Bi/Transgender/Transexual Issues:" & vbCrLf & _ vbTab & strLone & vbTab & strLtwo & vbTab & strLthree & vbCrLf & _ "Homelessness:" & vbCrLf & _ vbTab & strMone & vbTab & strMtwo & vbTab & strMthree & vbCrLf & _ "Informed Consent:" & vbCrLf & _ vbTab & strNone & vbTab & strNtwo & vbTab & strNthree & vbCrLf & _ "Literacy:" & vbCrLf & _ vbTab & strOone & vbTab & strOtwo & vbTab & strOthree & vbCrLf & _ "Outreach:" & vbCrLf & _ vbTab & strPone & vbTab & strPtwo & vbTab & strPthree & vbCrLf & _ "Participation in Treatment Planning:" & vbCrLf & _ vbTab & strQone & vbTab & strQtwo & vbTab & strQthree & vbCrLf & _ "Restraint and Seclusion:" & vbCrLf & _ vbTab & strRone & vbTab & strRtwo & vbTab & strRthree & vbCrLf & _ "Rural Issues:" & vbCrLf & _ vbTab & strSone & vbTab & strStwo & vbTab & strSthree & vbCrLf & _ "Stigma:" & vbCrLf & _ vbTab & strTone & vbTab & strTtwo & vbTab & strTthree & vbCrLf & _ "Tobacco Cessation/Reduction" & vbCrLf & _ vbTab & strUone & vbTab & strUtwo & vbTab & strUthree & vbCrLf & _ "Training Development:" & vbCrLf & _ vbTab & strVone & vbTab & strVtwo & vbTab & strVthree & vbCrLf & _ "Training CME/GRE:" & vbCrLf & _ vbTab & strWone & vbTab & strWtwo & vbTab & strWthree & vbCrLf & _ "Transition Age Youth:" & vbCrLf & _ vbTab & strXone & vbTab & strXtwo & vbTab & strXthree & vbCrLf & _ "Trauma:" & vbCrLf & _ vbTab & strYone & vbTab & strYtwo & vbTab & strYthree & vbCrLf & _ "Treatment Compliance:" & vbCrLf & _ vbTab & strZone & vbTab & strZtwo & vbTab & strZthree & vbCrLf & _ "Veterans Issues:" & vbCrLf & _ vbTab & strAAone & vbTab & strAAtwo & vbTab & strAAthree & vbCrLf & _ "Women's Issues:" & vbCrLf & _ vbTab & strABone & vbTab & strABtwo & vbTab & strABthree & vbCrLf & _ vbCrLf & _ "***** Entitlements *****" & vbCrLf & _ vbCrLf & _ "Social Security Administration Retirement:" & vbCrLf & _ vbTab & strACone & vbTab & strACtwo & vbTab & strACthree & vbCrLf & _ "Supplemental Security Income (SSI):" & vbCrLf & _ vbTab & strADone & vbTab & strADtwo & vbTab & strADthree & vbCrLf & _ "Social Security Disability Insurance (SSDI):" & vbCrLf & _ vbTab & strAEone & vbTab & strAEtwo & vbTab & strAEthree & vbCrLf & _ "Medicaid:" & vbCrLf & _ vbTab & strAFone & vbTab & strAFtwo & vbTab & strAFthree & vbCrLf & _ "Medicare:" & vbCrLf & _ vbTab & strAGone & vbTab & strAGtwo & vbTab & strAGthree & vbCrLf & _ "SSA Plan to Achieve Self-Sufficiency (PASS):" & vbCrLf & _ vbTab & strAHone & vbTab & strAHtwo & vbTab & strAHthree & vbCrLf & _ "SSA Impariment Related Work Expenses (IRWE):" & vbCrLf & _ vbTab & strAIone & vbTab & strAItwo & vbTab & strAIthree & vbCrLf & _ "1619B/1915B Extended Eligibility:" & vbCrLf & _ vbTab & strAJone & vbTab & strAJtwo & vbTab & strAJthree & vbCrLf & _ "Ticket to Work:" & vbCrLf & _ vbTab & strAKone & vbTab & strAKtwo & vbTab & strAKthree & vbCrLf & _ "Section 8 Vouchers:" & vbCrLf & _ vbTab & strALone & vbTab & strALtwo & vbTab & strALthree & vbCrLf & _ "Social Services:" & vbCrLf & _ vbTab & strAMone & vbTab & strAMtwo & vbTab & strAMthree & vbCrLf & _ "Aid to Families with Dependent Children (AFDC):" & vbCrLf & _ vbTab & strANone & vbTab & strANtwo & vbTab & strANthree & vbCrLf & _ "Energy Assistance:" & vbCrLf & _ vbTab & strAOone & vbTab & strAOtwo & vbTab & strAOthree & vbCrLf & _ "Enterprise Zones:" & vbCrLf & _ vbTab & strAPone & vbTab & strAPtwo & vbTab & strAPthree & vbCrLf & _ "Food Stamps:" & vbCrLf & _ vbTab & strAQone & vbTab & strAQtwo & vbTab & strAQthree & vbCrLf & _ "Temporary Assistance/Special Needs Accounts:" & vbCrLf & _ vbTab & strARone & vbTab & strARtwo & vbTab & strARthree & vbCrLf & _ "Veterans Benefits:" & vbCrLf & _ vbTab & strASone & vbTab & strAStwo & vbTab & strASthree & vbCrLf & _ "Workforce Investment Act:" & vbCrLf & _ vbTab & strATone & vbTab & strATtwo & vbTab & strATthree & vbCrLf & _ vbCrLf & _ "***** Evidence Based Practices *****" & vbCrLf & _ vbCrLf & _ "Assertive Community Treatment (ACT):" & vbCrLf & _ vbTab & strAUone & vbTab & strAUtwo & vbTab & strAUthree & vbCrLf & _ "Family Psycho-Education:" & vbCrLf & _ vbTab & strAVone & vbTab & strAVtwo & vbTab & strAVthree & vbCrLf & _ "Integrated Treatment Co-occuring Disorders:" & vbCrLf & _ vbTab & strAWone & vbTab & strAWtwo & vbTab & strAWthree & vbCrLf & _ "Intensive Case Management (ICM):" & vbCrLf & _ vbTab & strAXone & vbTab & strAXtwo & vbTab & strAXthree & vbCrLf & _ "Medication:" & vbCrLf & _ vbTab & strAYone & vbTab & strAYtwo & vbTab & strAYthree & vbCrLf & _ "Post Traumatic Stress Disorder Treatment:" & vbCrLf & _ vbTab & strAZone & vbTab & strAZtwo & vbTab & strAZthree & vbCrLf & _ "Supported Employment:" & vbCrLf & _ vbTab & strAAAone & vbTab & strAAAtwo & vbTab & strAAAthree & vbCrLf & _ "Self-Help Peer Support Services:" & vbCrLf & _ vbTab & strAABone & vbTab & strAABtwo & vbTab & strAABthree & vbCrLf & _ "Wellness Self-Management:" & vbCrLf & _ vbTab & strAACone & vbTab & strAACtwo & vbTab & strAACthree & vbCrLf & _ "Childrens: EB Prescribing Practices:" & vbCrLf & _ vbTab & strAADone & vbTab & strAADtwo & vbTab & strAADthree & vbCrLf & _ "Childrens: Family Ed. and Support Services:" & vbCrLf & _ vbTab & strAAEone & vbTab & strAAEtwo & vbTab & strAAEthree & vbCrLf & _ "Childrens: Functional Family Therapy:" & vbCrLf & _ vbTab & strAAFone & vbTab & strAAFtwo & vbTab & strAAFthree & vbCrLf & _ "Childrens: Homes Based Crisis Intervention:" & vbCrLf & _ vbTab & strAAGone & vbTab & strAAGtwo & vbTab & strAAGthree & vbCrLf & _ "Childrens: Home & Community Based Services:" & vbCrLf & _ vbTab & strAAHone & vbTab & strAAHtwo & vbTab & strAAHthree & vbCrLf & _ "Childrens: Intensive Case Management (ICM):" & vbCrLf & _ vbTab & strAAIone & vbTab & strAAItwo & vbTab & strAAIthree & vbCrLf & _ "Childrens: School Based Mental Health Services:" & vbCrLf & _ vbTab & strAAJone & vbTab & strAAJtwo & vbTab & strAAJthree & vbCrLf & _ "Childrens: PTSD Treatment:" & vbCrLf & _ vbTab & strAAKone & vbTab & strAAKtwo & vbTab & strAAKthree & vbCrLf & _ vbCrLf & _ "***** Other Issues of Importance *****" & vbCrLf & _ vbCrLf & _ "Child Custody / Parental Rights:" & vbCrLf & _ vbTab & strAALone & vbTab & strAALtwo & vbTab & strAALthree & vbCrLf & _ "Confidentiality:" & vbCrLf & _ vbTab & strAAMone & vbTab & strAAMtwo & vbTab & strAAMthree & vbCrLf & _ "Consumer/Survivor/Ex-Patients as staff:" & vbCrLf & _ vbTab & strAANone & vbTab & strAANtwo & vbTab & strAANthree & vbCrLf & _ "Creative Arts:" & vbCrLf & _ vbTab & strAAOone & vbTab & strAAOtwo & vbTab & strAAOthree & vbCrLf & _ "Cross Disability Issues:" & vbCrLf & _ vbTab & strAAPone & vbTab & strAAPtwo & vbTab & strAAPthree & vbCrLf & _ "Family Issues:" & vbCrLf & _ vbTab & strAAQone & vbTab & strAAQtwo & vbTab & strAAQthree & vbCrLf & _ "Involuntary Treatment:" & vbCrLf & _ vbTab & strAARone & vbTab & strAARtwo & vbTab & strAARthree & vbCrLf & _ "Mental Health Insurance Parity:" & vbCrLf & _ vbTab & strAASone & vbTab & strAAStwo & vbTab & strAASthree & vbCrLf & _ "Parenting Skills:" & vbCrLf & _ vbTab & strAATone & vbTab & strAATtwo & vbTab & strAATthree & vbCrLf & _ "Public Relations:" & vbCrLf & _ vbTab & strAAUone & vbTab & strAAUtwo & vbTab & strAAUthree & vbCrLf & _ "Rights Protection:" & vbCrLf & _ vbTab & strAAVone & vbTab & strAAVtwo & vbTab & strAAVthree & vbCrLf & _ "Self-Help Alternatives:" & vbCrLf & _ vbTab & strAAWone & vbTab & strAAWtwo & vbTab & strAAWthree & vbCrLf & _ "Suicide:" & vbCrLf & _ vbTab & strAAXone & vbTab & strAAXtwo & vbTab & strAAXthree & vbCrLf & _ "Transportation:" & vbCrLf & _ vbTab & strAAYone & vbTab & strAAYtwo & vbTab & strAAYthree & vbCrLf & _ "Voter Registration:" & vbCrLf & _ vbTab & strAAZone & vbTab & strAAZtwo & vbTab & strAAZthree Dim objCdoConfig Set objCdoConfig = CreateObject("CDO.Configuration") With objCdoConfig.Fields .Item(cdoSendUsingMethod) = cdoSendUsingPort .Item(cdoSMTPServer) = "mailscan.omh.ny.gov" .Update End With Set objMail = Server.CreateObject("CDO.Message") Set objMail.Configuration = objCdoConfig objMail.From = "webunit@omh.ny.gov" objMail.To = "Recipientaffairs@omh.ny.gov" objMail.Subject = "Mail List Form Response" objMail.TextBody = strMessageBody objMail.Send Set objMail = Nothing Set objCdoConfig = Nothing ' Display thank you page. Response.Redirect("thankyou.html") Else ' Input is not valid, display the page along with a message. End If Else ' User answered reCAPTCHA incorrectly. IsGoodCaptcha = False strCaptchaError = "&error=" & ResponseString(1) End If End If %> Mail List Form
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Office of Mental Health

Mail List Form

Completing this form will enable the Office of Consumer Affairs to prioritize issues for a recipient and family agenda, identify individuals like you who may be a resource to aid in policy and other discussions, and identify information and resource needs that exist.

Fields in bold are required. Place a check in each column next to each issue that you feel is appropriate. You may check more then one box for each issue. Once finished click on the "Submit" button located at the bottom of the page.











Would you be willing to serve on Boards or Committees?
Do you self-identify as someone who has used mental health services?
Do you self-identify as a family member of someone who has used services?

Clinical Issues

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value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
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value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
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Entitlements

Issues Would like more
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value="more information" /> value="be involved" /> value="very important" />
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value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
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value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />

Evidence Based Practices

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value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />

Other Issues of Importance

Issues Would like more
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value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
value="more information" /> value="be involved" /> value="very important" />
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Comments or questions about the information on this page can be directed to the Office of Consumer Affairs.