Through the Trauma Prevention Initiative, nonprofit agencies have the opportunity to request one-on-one technical support from a team of specialists contracted by the County Department of Public Health. If you and your agency are interested in participating in this facet of the TPI, please submit this request form no later than Friday, October 27, 2017.

If you have any questions, please contact:
Bill Martinez
Capacity Building Consultant
bilmartinez@ph.lacounty.gov

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* 1. Agency Information

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* 2. Year Agency Established

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* 3. Year incorporated as 501(c)3 agency

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* 4. Contact Person

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* 5. Website

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* 6. Annual Budget

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* 7. Number of Full-Time Staff

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* 8. Number of Part Time Staff

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* 9. Estimated number of individuals your agency serves annually

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* 10. Race/Ethnicity: What percentage of the individuals your agency serves are: (Please estimate to the best of your ability)

  Percentage
African-American
Latino
Asian-American
White
Native American
Bi-Racial

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* 11. Gender: What percentage of the individuals your agency serves are: (Please estimate to the best of your ability)

  Percentage
Female
Male
Transgender
Gender-Neutral

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* 12. Age: What percentage of the individuals your agency serves are: (Please estimate to the best of your ability)

  Percentage
0-5
6-12
13-17
18-24
25-34
35-64
65+

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* 13. In which of the following languages are your services provided:

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* 14. In which of the following communities does your agency provide service(s)? (Please check all that apply)

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* 15. Which community is your primary focus area? (Please check only one)

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* 16. Prevention and/or intervention services provided: (Please check all that apply)

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* 17. Top 5 Services (1st of 5)

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* 18. Top 5 Services (2nd of 5)

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* 19. Top 5 Services (3rd of 5)

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* 20. Top 5 Services (4th of 5)

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* 21. Top 5 Services (5th of 5)

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