Request to Review Program
Bureau for Behavioral Health Clearinghouse
Person requesting review
First Name
Last Name
Organization
Email
example@example.com
Is this program currently on the Bureau for Behavioral Health Clearinghouse?
Yes - submitting this program for re-review.
No - this is a new program for review.
Full Title of Program
Link to Program Website (if available)
What age range does this program serve, if known?
Is the program currently being offered in WV? If so, where is it offered?
Is the program listed on an existing registry? If so, which one(s)?
If the program is not on an existing registry, please provide link(s) to documented research study(ies) on the program.
Additional Notes or Comments
Submit
Should be Empty: