Information Request Form

Center for Community Collaboration

If have questions or would like to receive more information
about the Center for Community Collaboration, our work,
or any of our projects and materials, please fill out the form below.

Once you have completed the form, our staff will contact you to discuss your request.

Thank you for your interest!

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* 1. First Name

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* 2. Last Name

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* 3. Name of Agency/Organization (if applicable)

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* 4. Agency/Organization Address

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* 5. Job Title/Role

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* 6. Phone Number

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* 7. Email Address

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* 8. What type of services does your agency/organization provide?

Substance Use

Mental Health

Behavioral Health (both Substance Use and Mental Health services)

HIV Testing & Counseling

HIV/AIDS Medical Care and Support Services

Other Sexually Transmitted Infection Testing and/or Treatment

Sexual Health (e.g., sexual risk reduction counseling or other sexual health programming)

Primary Care Services

Pediatric and Adolescent Care

N/A - our agency/orgnaization does not provide services to clients

Other (please specify)

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* 9. Please list any questions you may have or provide details on the information/materials being requested.

Please feel free to contact us using the information below

Center for Community Collaboration

Department of Psychology

University of Maryland, Baltimore County

1000 Hilltop Circle

Baltimore, Maryland 21250

P: 410-455-5840

F: 410-455-3866

E: communitycollaboration@umbc.edu

W: http://communitycollaboration.umbc.edu/