Consulting Request Form
Submit your organization details and consulting needs to request review and potential support from Black Crown.
Organization & Contact Information
Organization Name
*
Contact Name
*
First Name
Middle Name
Last Name
Contact Title
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Website
Organization Type
*
Please Select
Public Agency
Private EMS Provider
Hospital/Health System
Fire Department
Municipality
Nonprofit
Educational Institution
Other
Location / Service Area
*
Requester Classification & Context
Requester Type
*
Licensed/Authorized EMS Agency
Non-Transport Program
Event Medical Program
Education/Training Program
Other
Consulting Need Category
*
Operational Review
Compliance Support
Protocol Development
Staff Training
Quality Improvement
Program Start-Up
Other
Current Problem
*
Desired Outcome
*
Timeline / Desired Start
*
Please Select
ASAP
Within 2 Weeks
Within 30 Days
1-3 Months
3+ Months
Flexible
Number of Providers/Staff Affected
Operational Scope & Internal Involvement
Is a medical director involved in this request?
*
Yes
No
Not sure
Is a legal or compliance officer involved in this request?
*
Yes
No
Not sure
Which areas does this request involve?
*
Clinical protocols
Training program design
QA/QI
Documentation audit
Onboarding
Policy/SOP development
Event/standby medical design
AI/workflow automation
Staffing/readiness
Deployment/disaster readiness
Equipment/readiness audit
Chart review workflow
Education/simulation
Leadership support
Grant/funding package
Custom needs
If you selected Custom needs, please describe them.
Preferred Engagement & Budget
Preferred engagement type
*
Discovery consult
Systems audit
Policy/SOP build
Training design
QA/QI rebuild
Event medical program build
Implementation retainer
Custom
Budget range
*
Please Select
Under $2,500
$2,500–$5,000
$5,001–$10,000
$10,001–$25,000
Over $25,000
Not sure yet
Attachments & Reference Materials
SOPs
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Sample Forms
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Training Outline
Upload a File
Drag and drop files here
Choose a file
Cancel
of
De-identified Audit Examples
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Org Chart
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Equipment Checklist
Upload a File
Drag and drop files here
Choose a file
Cancel
of
RFP
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Acknowledgments, Boundaries & Signature
Acknowledgment of consulting boundaries
*
Black Crown does not replace the agency medical director
Black Crown does not provide legal advice
Black Crown does not authorize clinical practice
Black Crown does not create final clinical protocols without agency medical director approval
Black Crown does not operate as ambulance or transport service
Black Crown does not access PHI unless a separate written agreement and privacy process are in place
Acknowledgment of review process
*
Submission is a request for review only
Submission does not guarantee acceptance or engagement
Signature
*
Submit Request
Submit Request
Should be Empty: