Pediatric TCPi Enrollment PTN Enrollment * 1. Practice and/or Health System NamePlease list the name that is registered to your clinic's TIN if possible; if you have any questions, please contact TCPI@doh.wa.gov. * 2. Is your practice Primary Care, Specialist, or Behavioral Health?Please choose the primary type of service your practice offers. If you have any questions, please contact TCPI@doh.wa.gov. Primary Care Behavioral Health Specialist * 3. Street Address (including suite number) * 4. City * 5. Zipcode+4 * 6. County * 7. Who is the main point of contact for your clinic? * 8. Point of contact title (Clinic Administrator, etc) * 9. Point of contact phone * 10. Point of contact email address * 11. Name of person submitting this form * 12. Phone number or email address of submitter A practice facilitator assigned to your clinic will be in touch with you via email shortly to set up an initial meeting to introduce the initiative. The initiative includes a Practice Assessment Tool, which will also be discussed during this first meeting. If you have any questions before that time, please reach out to Melissa Thoemke, Program Manager for P-TCPi (email@example.com). Thank you for enrolling!