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* 1. Name

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* 2. Title

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* 3. Organization

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* 4. E-mail Address

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* 5. Phone number

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* 6. How many school-based health centers are you interested in?  (Please refer to the models of care attached to the e-mail for a description).  This is a primary care provider, full-time and a full-time mental health provider.

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* 7. Do you have a partnering school-district, or sponsoring agency (who provides the healthcare) in mind?

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* 8. How many mental health sites are you interested in?  (Please refer to the models of care attached to the e-mail for a description).  This is a full-time mental health provider only.

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* 9. Do you have a partnering school-district, or sponsoring agency (who provides the mental healthcare) in mind?

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* 10. How many school-wellness program sites are you interested in?  (Please refer to the models of care attached to the e-mail for a description).  This is a full-time nurse and a full-time mental health provider.

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* 11. Do you have a partnering school-district, or sponsoring agency (who provides the healthcare providers) in mind?

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* 12. Comment Box for additional space or questions.  Thank you!

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