Social Risk Factors: Mental Health Learning Collaborative

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your title at your health center/organization?

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* 4. Please list any healthcare credentials you hold. Ex: RN, RD, etc.

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* 5. Are you currently employed by a heath center?

Yes

No

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* 6. What is the name of your health center or organization?

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* 7. Please provide your health center/organization address, including city, state, and zip code.

Street Address

City

State

Zip code

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* 8. Is there a second address you would like to include?

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* 9. What is your preferred email address?

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* 10. Do you currently have Behavioral/Mental Health services in place at your health center/organization?

Yes

No

Referral only, to an external program

No, but interested in learning more

Other (please specify)

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* 11. We ask that you commit to participating in all learning sessions in order to register for this Learning Collaborative. By checking the box below, you indicate your commitment to participating in all sessions.
There will be 4 sessions held from 2-3:30pm CST on the following dates:

February 11, 2025

February 18, 2025

February 25, 2025

March 4, 2025

Yes, I agree to commit to participating in all 4 sessions.

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* 12. Supervisor approval is required for participation in this Learning Collaborative. By checking the box below, you indicate that you have received approval from a supervisor.

Yes, I have received supervisor approval to participate.

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* 13. Would you like to be added to the NCFH mailing list to learn more about NCFH services and upcoming events?

Yes, please.

No, thank you.

I am already on the list.