VTMHI Referring Partner Application
Thank you for your interest in becoming a referring partner with the Virginia Telemental Health Initiative! Please complete this form as thoroughly as possible to submit your clinic as a potential partner. A member of the VTMHI team will follow up regarding the next steps. If you have any questions, please contact Johanna Henz (johanna@ehealthvirginia.org).
Clinic Name
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Name of person completing application
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First Name
Last Name
Your title/role
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Email
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example@example.com
What geographic areas are served by the clinic?
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Please list the clinic's eligibility requirements.
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Is your clinic currently providing therapeutic (non-medication management) mental health services?
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Yes
No
If yes, please explain.
Do you currently have a waitlist for therapeutic (non-medication management) mental health services?
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Yes
No
If yes, how many patients are currently on the waitlist (please provide an estimated percentage of uninsured, Medicaid, and private insurance)? What is the current average wait time?
Please outline your plan to identify and recruit eligible patients who are interested in telemental health services.
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Provide an estimated percentage breakdown of the primary languages spoken by the patients served by your clinic.
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What particular populations served by your clinic may require specialized knowledge or experience to effectively serve?
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Does the clinic have a plan for responding to a patient safety concern? Is there a protocol for concerns identified during a telehealth appointment?
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Do you have a mental health community resource list (e.g., local crisis options, peer groups, etc.) that could be provided to volunteers?
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Yes
No, but we could develop one
No
Please select all of the following that apply to your clinic:
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Our clinic is a member of VAFCC.
Our clinic is an associate member of VAFCC.
We have confidential space for patients to receive telemental health services in the clinic.
We have a computer/laptop or iPad with reliable internet access for patients to use for telemental health visits in the clinic.
We have a crisis response process in place.
We are willing to develop a crisis response process.
Our clinic can/will provide patient eligibility information at the time of referral.
Have you received leadership and organizational approval and support to begin a referral partnership with VTMHI?
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Yes
No
Other
Is there any information about your clinic that you think would be helpful for us to know?
Do you have any questions or concerns about VTMHI?
Please tell us why you're interested in this partnership and how you think it could impact your clinic and patient population.
By digitally signing this application I attest that all information provided is accurate and complete.
Signature
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By digitally signing this application I attest that all information provided is accurate
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