Team-Based Care ECHO Registration Survey

Thank you for your interest in applying for the Team-based Care ECHO Learning Collaborative! Because we have met the cap on the number of participants that has been accepted into this opportunity, registration forms are now closed. All other submissions will be added to the wait list to join this opportunity when space allows.

If you have any questions, please check out our participant FAQ document or email us at integration@thenationalcouncil.org.

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* 1. Contact Information

Name

Organization Name

Title

State/Province

ZIP/Postal Code

Email Address

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* 2. Organization Type

Community Behavioral Health Clinic (CBHC)

Certified Community Behavioral Health Clinic (CCBHC)

Federally Qualified Health Center (FQHC)

Substance Use Provider Organization

Other Mental Health Organization

Other Primary Care Organization

Other (please specify)

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* 3. Please describe the population served by your organization.

Rural

Urban

Suburban

Frontier

Other (please describe)

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* 4. How would you rate your knowledge of Team-Based Care (TBC)?

We are learning and exploring more about TBC

We are in the process of implementing TBC

We consider ourselves experts in TBC

We consider ourselves expert in TBC and are interested in sharing our progress and lessons learned with others

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* 5. How would you define TBC and how is it being used to improve outcomes and experiences for clients and staff within your organization?

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* 6. Is there a particular aspect of TBC you would like more assistance with?

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* 7. What do you hope to gain from being involved in this ECHO Learning Collaborative series?

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* 8. It is strongly recommended that participants attend every ECHO session, or as many as they can. This will make the learning much more meaningful and will ensure each participant gets the most out of this opportunity. Please check this box if you are committed to attending and participating in at least 7 or the 10 ECHO sessions.

I agree