Act_PIPLE Registration

Peer Impact Panel: Advancing the Role of Peers in Integrated Care Systems Registration
Wednesday, May 27, 2-3:30 p.m. ET

This virtual session is supported by the Center of Excellence for Integrated Health Solutions, funded by a grant award from the U.S. Department of Health and Human Services. If you have questions about these sessions, please contact Integration@TheNationalCouncil.org.
Name

First NameLast Name
Email
example@example.com
State/Province/Island Area
Zip/Postal Code
Which best describes your agency/organization

Mental health provider organizationSubstance use provider organizationPrimary care provider organizationGovernment (federal, state, tribal, island area, local)Education or research instituteAssociation, coalition, or network-for-advocacy, professionals, or individualsBusiness (health management, insurer, or other industry)Other, please specify
Are you a SAMHSA Promoting the Integration of Primary and Behavioral Health Care (PIPBHC) recipient or provider organization?

Yes, I am a current PIPBHC: Collaborative Care Model (CoCM) recipientYes, I am a current PIPBHC: Collaborative Care Model (CoCM) provider organizationYes, I am a current PIPBHC: States recipientYes, I am a current PIPBHC: States provider organizationYes, I am a current PIPBHC: PIPBHC recipientYes, I am a former PIPBHC recipient or provider organizationYes, I am a current PIPBHC: PIPBHC recipientNoI don't know
PIPBHC State Recipient Name
PIPBHC CoCM Recipient Name
PIPBHC CoCM Provider Organization Name
PIPBHC States Provider Organization Name
Organization Name
Where is your organization in the process of integrating behavioral health and primary care?

Advanced/Full ImplementationBeginning ImplementationLearning/ExploringNot applicableOngoing Quality ImprovementOther, please specify
Is your organization a Certified Community Behavioral Health Clinic (CCBHC)?

YesNoUnsure
Is your organization a National Council for Mental Wellbeing member?

YesNoUnsure
Are you interested in joining the Center of Excellence for Integrated Health Solutions listserv?
Should be Empty:

Peer Impact Panel: Advancing the Role of Peers in Integrated Care Systems Registration