Empowering CCBHCs for Overdose Safety Information Session Registration

Empowering CCBHCs for Overdose Safety Informational Session Registration
Organization Name*
Name*

First NameLast Name
City*
State*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Job Category*

CCBHC Program DirectorManagement/Administrator/ExecutiveClinical/Mental Health or Substance Use ProfessionalParaprofessional/Peer Support/Care Coordination/Case ManagementEvaluation/Data Management/AnalystGrants Management/ComplianceQuality Improvement/AssuranceAdministrative Support StaffFinancial/Reimbursement/Billing StaffConsultant/ContractorOther
Do you need translation services during the event?*

YesNo
If Yes, What language would you like to request translation services ?
Demographic Information

Disclaimer: The demographic information collected for registration is optional to provide and will be used to measure and report aggregate analysis on the racial, ethnic, and gender composition of the TTA Center’s audience to inform understanding of the diversity of participation and improve the reach of our events. This demographic information be held in strict confidence and will not be shared with any third parties and will not be used at an individual level.
How would you describe yourself?
Which of the following best describes your gender?
Which of the following best describes your sexual orientation?
CCBHC Status
What is your organization’s CCBHC status? (Select all that apply)*

CCBHC Expansion GranteeMedicaid CCBHC Demonstration SiteIndependent State Certified CCBHCProspective CCBHC/Interested in Adopting the ModelCurrent CCBHC PartnerState Government Official or Policy MakerOther
If you are CCBHC Expansion grantee, what year were you awarded your grant? (Select all that apply)*

2017201820192020202120222023
What is your CCBHC Status?*

CCBHC PDI GranteeCCBHC IA GranteeOther
How would you describe your knowledge about the CCBHC model?*

Limited knowledge on the CCBHC model – minimal past education or learning onthe CCBHC model, new staff on the project team who do not know CCBHCModerate knowledge on the CCBHC model – some foundational knowledge onCCBHC, have participated in webinars, events or reviewed resources, a lot ofresearch on the model was conducted before applyingStrong foundational knowledge of the CCBHC model – clear understanding ofthe criteria, have been educating and training staff and stakeholders on themodel, some staff may have experience in implementing the model
Which of the following clinical areas are you most in need of support? (Select all that apply)*

Behavioral health workforceStaffing and licensureCare CoordinationCrisis ServicesTargeted Case ManagementPsychiatric Rehabilitation ServicesPeer SupportPrimary Care Screening and MonitoringEvidence-Based Practice AdoptionScreening, assessment and diagnosisIntegrated CareOutpatient Substance Use ServicesOutpatient mental health servicesSustainability
Which other areas are you most in need of support? (Select all that apply)*

Billing and reimbursementData collection, reporting and analysisCCBHC partnershipsData sharing and/or interoperabilityFinancial management and sustainabilityHealth information technologyManaging organizational changeUnderstanding the CCBHC model and criteria
What type of support is most beneficial to you? (Select all that apply)*

Direct ConsultationLearning CommunitiesOn-Demand ResourcesWebinars and Office HoursPeer to Peer Support
Session-Specific Questions
What questions would you most like answered in this session?*
Would you like to receive emails on upcoming events from the TTA Center?*

YesNo
Would you like to receive emails on upcoming events from Zero Overdose?*

YesNo
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Empowering CCBHCs for Overdose Safety Informational Session Registration

Demographic Information

CCBHC Status

Session-Specific Questions