Telehealth Expansion Program: Provider Interest Survey The New Jersey Pediatric Mental Health Access Program is a Telehealth Expansion Program funded through a grant by The Human Resources Services Administration (HRSA) to serve as an enhancement of the New Jersey Pediatric Psychiatry Collaborative (NJPPC) Program. Thank you for taking the time to complete our brief Telehealth Provider Interest Survey. This should take approximately 5 minutes to complete. The information you provide will help us to best accommodate your practice's needs for telehealth/telepsychiatry services. If you are not yet a member of the NJPPC, please visit our website at https://njaap.org/mental-health/njppc/or email a member of our team at MHC@njaap.org. OK Question Title * 1. Demographics Name of the person completing this form Name of the provider interested in the telehealth expansion program Credentials (MD, DO, APN, PA, etc.) Provider's Email Practice Name City/County OK Question Title * 2. Is the provider currently a registered NJPPC member? Yes No If No, are you interested in learning more about how to become a member? OK Question Title * 3. Is the provider currently utilizing telehealth in their practice? Yes No OK Question Title * 4. What telehealth videoconferencing is your practice set up to use? Check all that apply. Zoom Doxy Me WebEx Microsoft Teams Other (please specify) OK Question Title * 5. Do you utilize an Electronic Medical Record system in your practice? No Yes If Yes (please specify) OK Question Title * 6. Please fill in the information below for the practice team member who can serve as the best point of contact for our Telehealth team. Name of best point of contact: Title/Role of point of contact: Direct phone number: Email: OK Thank you! OK DONE