SCOPE-OK Consortium Membership Registration

Thank you for your interest in joining SCOPE-OK! Please fill out the below information and we will add you to our consortium meetings calendar invitation and all future communications.

Question Title

* 1. Let us know who you are!

Name *

Company *

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 2. What type of organization are you affiliated with?

Critical Access Hospital

Small Rural Hospital (49 beds or less)

Other Hospital (sole community, rural referral center, etc.)

Emergency medical services

Federally Qualified Health Center (FQHC)

FQHC Look-alike

Local or state health department

Mental and behavioral health organization, practice, or provider

Primary care practice or provider

Rural Health Clinic

Ryan White HIV/AIDS Clinic

Methadone clinic

Opioid treatment program

Substance abuse treatment provider- other

Community based organization

Cooperative extension system office

Law enforcement

Court system

Prison

Probation and parole

Faith-based organization

Health Start site

HIV and HCV prevention organization

Maternal, infant, and early childhood home visiting program local implementation agency

Poison Control Center

Primary Care Association (PCA)

Primary Care Organization (PCO)

Recovery Community Organization (RCO)

Research/Academic organization

School system

Single State Agency (SSA)

Tribe/Tribal organization

Other (please specify)

Question Title

* 3. Please select the type of prevention, treatment, or recovery services your organization offers (Select all that apply).

Prevention services (not including naloxone)

Screening and/or assessment services

Medication-Assisted Treatment (with or without psychosocial) (MAT)

SUD/OUD treatment other than MAT

Infectious disease testing (i.e., HIV or HCV)

Recovery support services

Mental health treatment

We do not provide SUD/OUD prevention, treatment, or recovery services

Other (please specify)

Question Title

* 4. Please select the type of harm reduction services your organization offers (Select all that apply).

Naloxone access

Syringe services

Fentanyl test strips

Pipe access

Sex worker services

We do not offer any harm reduction services.

Other (please specify)

Question Title

* 5. Does your organization receive additional funding for SUD/OUD prevention, treatment, or recovery activities? This can be federal, state, insurance, etc.

Yes

Question Title

* 6. Are you a person with lived experience with substance use disorder/opioid use disorder? (Examples- person in recovery, impacted family member or friend, currently using drugs, in treatment, etc.)

Yes

I prefer not to say

SCOPE-OK Consortium Membership Registration

Question Title

* 1. Let us know who you are!

Question Title

* 2. What type of organization are you affiliated with?

Question Title

* 3. Please select the type of prevention, treatment, or recovery services your organization offers (Select all that apply).

Question Title

* 4. Please select the type of harm reduction services your organization offers (Select all that apply).

Question Title

* 5. Does your organization receive additional funding for SUD/OUD prevention, treatment, or recovery activities? This can be federal, state, insurance, etc.

Question Title

* 6. Are you a person with lived experience with substance use disorder/opioid use disorder? (Examples- person in recovery, impacted family member or friend, currently using drugs, in treatment, etc.)

Question Title

* 7. How did you hear about SCOPE-OK?