Outside Organizations: Presenting to Nystrom Staff Form

(Approval Required)

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* 1. NAME OF YOUR ORGANIZATION

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* 2. NAME OF NYSTROM STAFF THAT REFERRED YOU

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* 3. YEARS YOUR ORGANIZATION HAS BEEN IN BUSINESS

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* 4. WHERE IS YOUR ORGANIZATION LOCATED? (CITY/CITIES)

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* 5. CORPORATE NAME

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* 6. CORPORATE MAILING ADDRESS

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* 7. YOUR ORGANIZATION'S WEBSITE URL:

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* 8. INTAKE AND/OR REFERRAL CONTACT PRIMARY EMAIL

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* 9. INTAKE AND/OR REFERRAL CONTACT PRIMARY PHONE NUMBER

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* 10. FORMS OF PAYMENT (Check All That Apply)

CONSOLIDATED FUNDING

IN-NETWORK INSURANCE

MEDICAID

MEDICARE

OUT-OF-NETWORK INSURANCE

PRIVATE-PAY/CASH

RULE 25

SCHOLARSHIP

SLIDING SCALE

OTHER

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* 11. GENDERS SERVED (Check All That Apply)

All

FEMALE

MALE

TRANSGENDER

OTHER

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* 12. AGES SERVED

Under 18

18 +

Other (please specify)

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* 13. TYPE OF SERVICES YOUR ORGANIZATION PROVIDES

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* 14. CLINICAL MODALITIES (CBT, DBT, 12-STEP, EMDR, ETC.)

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* 15. PROGRAM DESCRIPTION

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* 16. ADDITIONAL INFORMATION ABOUT SERVICES:

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* 17. Nystrom Location(s) Requested

Apple Valley

Bloomington

Big Lake

Brainerd/Baxter

Cambridge

Coon Rapids

Duluth

Eden Prairie

Otsego

Maple Grove

New Brighton

Minnetonka

Rochester

Sartell/St. Cloud

Woodbury

Mankato

Other

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* 18. WHICH NYSTROM PROVIDERS DO YOU PREFER TO PRESENT TO? (not a guarantee they will all be in attendance)

Psychiatry & Medication Services

Counseling & Psychotherapy Services

Community Based Services

Psychological Testing

Drug and Alcohol Treatment (Substance Use Disorder)

Adult Day Treatment (ADT)

School-Based Mental & Chemical Health

Mother Baby Intensive Outpatient Program

Nutrition Counseling

Other

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* 19. WHAT SPECIFICALLY DO YOU WANT TO SHARE WITH NYSTROM STAFF?

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* 20. IS THIS A LUNCH A LEARN?

Yes

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* 21. WILL CONTINUING EDUCATION CREDITS BE PROVIDED?

Yes

Outside Organizations: Presenting to Nystrom Staff Form

(Approval Required)

Question Title

* 1. NAME OF YOUR ORGANIZATION

Question Title

* 2. NAME OF NYSTROM STAFF THAT REFERRED YOU

Question Title

* 3. YEARS YOUR ORGANIZATION HAS BEEN IN BUSINESS

Question Title

* 4. WHERE IS YOUR ORGANIZATION LOCATED? (CITY/CITIES)

Question Title

* 5. CORPORATE NAME

Question Title

* 6. CORPORATE MAILING ADDRESS

Question Title

* 7. YOUR ORGANIZATION'S WEBSITE URL:

Question Title

* 8. INTAKE AND/OR REFERRAL CONTACT PRIMARY EMAIL

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* 9. INTAKE AND/OR REFERRAL CONTACT PRIMARY PHONE NUMBER

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* 10. FORMS OF PAYMENT (Check All That Apply)

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* 11. GENDERS SERVED (Check All That Apply)

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* 12. AGES SERVED

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* 13. TYPE OF SERVICES YOUR ORGANIZATION PROVIDES

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* 14. CLINICAL MODALITIES (CBT, DBT, 12-STEP, EMDR, ETC.)

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* 15. PROGRAM DESCRIPTION

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* 16. ADDITIONAL INFORMATION ABOUT SERVICES:

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* 17. Nystrom Location(s) Requested

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* 18. WHICH NYSTROM PROVIDERS DO YOU PREFER TO PRESENT TO? (not a guarantee they will all be in attendance)

Question Title

* 19. WHAT SPECIFICALLY DO YOU WANT TO SHARE WITH NYSTROM STAFF?

Question Title

* 20. IS THIS A LUNCH A LEARN?

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* 21. WILL CONTINUING EDUCATION CREDITS BE PROVIDED?

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* 22. Other comments