Data Mapping and Collaborative Documentation - Participation Application Survey

Contact Information

Provided by the National Council for Mental Wellbeing and SAMHSA, this is an opportunity for CCBHC grantees to apply and participate in direct consultation with MTM Services for Data Mapping and/or Collaborative Documentation. This a 5-6 month commitment.
Completion of this application indicates that the organization is committed to participating in this opportunity, if selected.
Lack of attendance/participation may result in cancellation of an organization’s acceptance.
Grantees chosen to participate will receive these services free of charge to their organization, sponsored by the CCBHC-E National Training and Technical Assistance Center.

Applications will be accepted through Monday, April 7, 2025

1.This application is for the following consultation options: (Check one or more)(Required.)

Data Mapping

Collaborative Documentation

2.What is your CCBHC Status?(Required.)

CCBHC PDI Grantee

CCBHC IA Grantee

Other (please specify)

3.Please enter your demographic information(Required.)

Contact Person

Organization name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

4.Please enter the following information about the Executive Director / CEO on your team.(Required.)

Name

Email Address

5.Please enter the following information about the COO on your team.(Required.)

Name

Email Address

6.Please enter the following information about the CFO on your team.

Name

Email Address

7.Please enter the following information about the Quality Improvement / Utilization Management leader on your team.(Required.)

Name

Email Address

8.Additional stakeholders.

Name

Title

Email Address

9.Additional stakeholders.

Name

Title

Email Address