Partnership Interest Form

Partnership Interest Form

Submit your organization's interest in partnering with the Arizona Problem Gambling Peer Support Program.
SECTION 1: Organization Information

Tell us about your organization.
Organization Legal Name*
DBA/Common Name (if different)
Organization Type*

HealthcareBehavioral HealthSocial ServicesGovernmentNonprofitEducationLegal/FinancialOther
Main Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City*
County*
Primary Service Area*
Website*
Year Established*
Number of Staff*
Annual Clients Served*
SECTION 2: Primary Contact

Main point of contact for partnership inquiries.
Full Name*

First NameLast Name
Title/Role*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Best Time to Contact*

MorningAfternoonEveningFlexible
Secondary Contact Name (optional)
Secondary Contact Phone
Please enter a valid phone number.
Secondary Contact Email
example@example.com
SECTION 3: Partnership Interest

Select your areas of partnership interest.
What type of partnership are you interested in? (Select all that apply)*

Referral Partnership – Simple client referral pathwayMaterials Placement – Display our brochures/cards in your facilityCo-Hosted Events – Joint workshops, health fairs, or community eventsResource Sharing – Cross-promotion in newsletters/social mediaOther
Why are you interested in partnering with our program?*

Need gambling-specific resources for clientsWant to expand service continuumAddressing co-occurring issues in population servedMandate to provide comprehensive servicesOther
How many clients do you estimate might benefit from peer gambling support annually?*

1–1011–5051–100100+Unsure
SECTION 4: Current Services & Population

Tell us about the populations you serve and your current services.
Primary populations served (Select all that apply)*

General PublicVeteransYouth/Young AdultsSeniorsFamiliesJustice-InvolvedHomeless/Unstably HousedTribal CommunitiesLGBTQ+Immigrants/RefugeesRural CommunitiesOther
Does your organization currently screen for problem gambling?*

YesNoSometimes
Does your organization currently have staff trained in problem gambling?*

YesNo
Does your organization currently have existing gambling-specific resources?*

YesNo
If yes, describe current gambling-related services/resources*
SECTION 5: Preferred Collaboration

Share your preferences for collaboration and communication.
Referral Process Preference*

Warm handoff (joint conversation with client)Secure email referralPhone consultationOnline form submissionClient self-referral with your recommendation
SECTION 6: Timeline & Next Steps

Help us understand your timeline and additional needs.
Preferred Partnership Start Date*

MonthDayYear
Date
Urgency*

ImmediateNext 30 daysNext 90 daysFlexible
Any upcoming events or opportunities for collaboration?

YesNo
If yes, explain the details of the upcoming events/opportunities*
Additional comments or questions
SUBMISSION & FOLLOW-UP

Partnership Questions:
📧 Email: Azpartnerships@dezerve.info

Our Commitment:
We will contact you within 7 business days to discuss partnership opportunities. All information is confidential and used solely for partnership development.

Program Contact Information:
Arizona Problem Gambling Peer Support Program

📞 1-833-404-9526

✉️ Azpeersupport@dezerve.info

🌐 www.Dezerve.info/az-problem-gambling

Funded by Arizona Department of Gaming, Division of Problem Gambling
A program of Dezerve Counseling LLC
Should be Empty:

Partnership Interest Form

SECTION 1: Organization Information

SECTION 2: Primary Contact

SECTION 3: Partnership Interest

SECTION 4: Current Services & Population

SECTION 5: Preferred Collaboration

SECTION 6: Timeline & Next Steps