MakeAChoice.org: Become a Program Delivery Partner
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1.
Organization Name
(Required.)
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2.
Contact Name
(Required.)
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3.
Contact Email
(Required.)
4.
Programming Location or Area Served
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5.
Contact Phone Number:
(Required.)
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6.
Programs you currently run:
(Required.)
National Diabetes Prevention Program (DPP)
Diabetes Self Management Program (DSMP)
Diabetes Self Management Education and Support (DSMES)
Chronic Disease Self Management Program (CDSMP)
Chronic Pain Self Management Program (CPSMP)
Walk With Ease (WWE)
Other (please specify)
None of the above
7.
Do you provide in-person or virtual programming?
In-person
Virtual
Both
8.
Are you interested in receiving referrals from the Make A Choice - Health Referral Hub?
Yes
No
9.
Populations Served?
Spanish Speaking
Older Adults
People with Disabilities
Medicare and/or Medicaid Beneficiaries
Other (please specify)