Partnership Inquiry

Contact Information

Prefix Prefix

Name

Last name

Work title  (If individual please write N/A)

Address

City

State/Province

Zip/Postal

Country

Email

Phone

Are you inquiring on behalf of an  organization?

Yes

No

If not part of an organization, please visit our training page

I’m looking for support for:

Myself

My team

About Your Project

Location of program

City

State/Province

Zip/Postal

Country

Please select what your goal is :

The project is related to : The project is related to :

Who is your target population? Who is your target population?

Do you have a time frame or deadline?

Next # of days (up to 30)Next # of days (up to 30)

Next 30 days

Next 90 days

Next year

How many participants?

Please register for our next workshop

Does this represent an opportunity for systemic change?

Yes

No

I’m not sure

Please elaborate

Are you one of the following:

Network of clinics

School district

Community mental health  committees

Are you a federally qualified health center?

Do you have funding sources or budget in place?

Do you need support identifying funding sources?

Is this a collaboration?

List other collaborators:

Steering committeesSteering committees

Community organizationsCommunity organizations

Public or private entitiesPublic or private entities

Please provide any additional context

How did you find us?

I’m an alumna/us

I know someone who participated in training

Learned about it through an  article/podcast

Researching solutions for my institution

Read a book authored by Dr. Gordon or CMBM faculty

Social media

Internet search

Other

If search,  what keywords did you use

Please specify a source