ESE Mental Health Grant Application
School District
Name
First Name
Last Name
Title/Position
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Total number of schools needing the ESE TeleMental Health Program
Please explain the level of need for ESE TeleMental Health Program within the school district
Please describe how the program will be utilized at each school location
Do you understand and agree the ESE TeleMental Health Program will be used on a daily basis?
Yes
No
Signature
Continue
Continue
Should be Empty: