LOCUS Cohort Pre-Approval Form
You only need to fill this application out once

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* 1. Name (first & last):

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* 2. Company:

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* 3. Title:

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* 4. Email Address:

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* 5. Do you work for a CMHSP and/or contract agency of a CMHSP? Also please list Agency name.

Yes

Agency Name:

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* 6. Do you provide services to adults who struggle with severe mental illness and/or co-occurring disorders? (Does not include providing to parents of children/adolescents served in the CMHSP system.)

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* 7. Do you utilize the LOCUS?

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* 8. Do you plan on being a LOCUS trainer?

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* 9. Do you plan on providing training on the LOCUS to support sustainability and reliability within your CMHSP system?

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* 10. Please Upload your Basic LOCUS Certification (4 hour class) or Journey Health (Example images below- This is needed to fully complete the cohort series)

Hit upload and upload both certificates. This is needed to receive the Cohort Training Certificate. (After attendance to four cohorts)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 11. Please Upload your Deerfield Behavioral Certificate OR LOCUS Train-the-Trainer Certificate. (Example images below- This is needed to fully complete the cohort series)

Hit upload and upload both certificates. This is needed to receive the Cohort Training Certificate. (After attendance to four cohorts)

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

LOCUS Cohort Pre-Approval Form
You only need to fill this application out once

Question Title

* 1. Name (first & last):

Question Title

* 2. Company:

Question Title

* 3. Title:

Question Title

* 4. Email Address:

Question Title

* 5. Do you work for a CMHSP and/or contract agency of a CMHSP? Also please list Agency name.

Question Title

* 6. Do you provide services to adults who struggle with severe mental illness and/or co-occurring disorders? (Does not include providing to parents of children/adolescents served in the CMHSP system.)

Question Title

* 7. Do you utilize the LOCUS?

Question Title

* 8. Do you plan on being a LOCUS trainer?

Question Title

* 9. Do you plan on providing training on the LOCUS to support sustainability and reliability within your CMHSP system?

Question Title

* 10. Please Upload your Basic LOCUS Certification (4 hour class) or Journey Health (Example images below- This is needed to fully complete the cohort series)

Question Title

* 11. Please Upload your Deerfield Behavioral Certificate OR LOCUS Train-the-Trainer Certificate. (Example images below- This is needed to fully complete the cohort series)

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LOCUS Basic Course (Online/4 hours- not provided by CMHA)

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LOCUS Train-The-Trainer Certificate (Provided by Deerfield or CMHA)