Intake Form

Please answer the following questions about the support you’re interested in receiving as part of technical assistance for HCA's Tribal Opioid Solutions Campaign and DOH's Tribal Suicide Prevention Campaign. Once we receive and review your information, we will reach out to schedule a kickoff call. We look forward to working with you!

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* 1. Which Tribe / Tribal organization are you representing?

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* 2. What is your name, title, email and phone number?

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* 3. What campaign topics are of interest to you?

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* 4. Please mark any of the following forms of communications support your Tribe / Tribal organization would use to implement the campaign in your community (select all that apply).

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* 5. Please mark any of the following paid advertising channels your Tribe / Tribal organization would be interested in (select all that apply).

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* 6. What else do you feel is important for us to know as we provide support and develop campaign materials for your Tribe / Tribal organization to be used for opioid misuse prevention and treatment education and/or suicide prevention?

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