Child Mental Health Wraparound (CMHW) Provider Interest Survey

Thank you for your interest in becoming a provider for the Child Mental Health Wraparound (CMHW) program. As the first step in the process, please complete this general interest survey.

Please note this form is for individuals interested in becoming a provider. If you are already an authorized provider for the CMHW program, do not complete this form. Instead email your question, concern or request to DMHAyouthservices@fssa.in.gov

To learn more about the CMHW program it is strongly advised that you review the Child Mental Health Wraparound Services (CMHW) Program Manual.

1.Name as it appears on your Driver's License.(Required.)

2.Email address(Required.)

3.Select the service(s) you are interested in providing. Select all that apply.(Required.)

Habilitation - Direct services to youth to build functional skills

Family Support Training - Direct services to caregivers to build skills that support preservation of the family unit

Respite - Provides the caregiver with a break and provides recreational support to the youth

4.Are you interested in becoming an individual provider or are you interested in establishing an accredited or non accredited agency. Individual providers work for themselves and accredited and non-accredited agencies are allowed to hire individuals to work for them. Select one.(Required.)

Individual Provider

Non Accreditted Agency

Accredited Agency

6.Youth with serious emotional disturbance (SED) are youth who have diagnosed mental, behavioral, or emotional disorder that significantly impairs their ability to function in their family, school, or community. The impairments last long enough to meet diagnostic criteria.

Do you have experience directly working with youth aged 6-17 with SED(Required.)

Yes

7.If you have experience working with youth with SED between the age of 6-17. Please provide the month and year of your most recent experience working with this population. If no experience, enter "no experience".(Required.)

8.How many total years of experience do you have working with youth 6-17 with SED.(Required.)

9.Please describe your experience working with youth with SED. If no experience, enter "no experience".(Required.)

10.How did you hear about the CMHW program?(Required.)

I know someone who provides services for the program

I know a family who receives services from the program

I heard about the program through social media

I learned about the program though my own internet search

I am a former participant in the program

Other

11.By typing my name and date below, I attest that the information I have provided in this survey is true, accurate and complete to the best of my knowledge. I understand that completing this survey does not guarantee approval.(Required.)

Enter name

Enter date

Your responses to this survey will be reviewed and you will be sent communication to the email address provided in this survey. The email you receive will advise on next steps. Please be sure to check your spam inbox. Questions can be sent to DMHAyouthservices@fssa.in.gov