Request Form

TA Recipient/Requestor*

E-mail Address*

Programmatic Email (if available)

Phone Number

Position/Title

Location (State/Territory/Tribe/County/City as app

Do you have an IECMHC Program you are seeking support for?*

IECMHC Program is defined as more than one IECMH Consultant working collectively to provide IECMHC services. https://www.iecmhc.org/about/

Select or enter value

Please provide a brief IECMHC program description including (estimates are fine and if this information is not known because the program is in the development phase, please provide as much information as is known):*

Size (number of consultants)
Population served
Setting(s) served
Where the program is housed ((e.g., within a university, a clinic, a state or city government department)

Program Name*

Is your program part of a federal grant program?

Select

If other, name of other federal grant program(s)

We are planning to use ARPA dollars to develop/expand IECMH consultation in our state

What is the area you are most interested in for technical assistance? Examples are intended only to help explain the areas; your technical assistance request may vary!*

Select or enter value

On a scale of 1-5, where are you in the process of developing and implementing an evidence based IECMHC model?

Select

TA Request*

Are you requesting TA specifically related to IECMHC during the COVID-19 pandemic?

(check box if yes, leave blank if no)

If yes, please provide more details in the text box below

By participating in technical assistance, I am agreeing to the following terms:*

-I understand that Technical Assistance is provided through funding from SAMHSA. To support compliance with funding requirements, I may be asked to complete one or more brief evaluation surveys about my experiences with Technical Assistance. I agree that I will complete these surveys in a timely manner. -I understand that my contact information and program name may be shared with the Center of Excellence’s partners and Consultation Council for the purpose of coordinating across related systems and ensuring that my program receives high-quality services and resources. More information on the Center of Excellence’s partners can be found here: https://www.iecmhc.org/about/partners/.

Attachments

Please attach anything that will help us with your request.

Drag and drop files here or

Send me a copy of my responses

Privacy Notice|Report Abuse