Pediatric TCPi Enrollment PTN Enrollment Question Title * 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. Question Title * 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 Question Title * 3. Street Address (including suite number) Question Title * 4. City Question Title * 5. Zipcode+4 Question Title * 6. County Question Title * 7. Who is the main point of contact for your clinic? Question Title * 8. Point of contact title (Clinic Administrator, etc) Question Title * 9. Point of contact phone Question Title * 10. Point of contact email address Question Title * 11. Name of person submitting this form Question Title * 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 (firstname.lastname@example.org). Thank you for enrolling!