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Healthcare Resource Assessment - Behavioral Health
This survey is designed to collect information on those assets that your agency may access, activate, deploy, etc. during an event.
Email address *
1. Name of Behavioral Health Organization: *
Your answer
2. Location of facilities (check all that apply): *
Required
3. Jurisdictions served (select all that apply): *
Required
4. 24/7 primary organization contact - Name: *
Your answer
5. 24/7 primary organization contact - Phone: *
Your answer
6. 24/7 primary organization contact - E-mail: *
Your answer
7. 24/7 alternate organization contact - Name:
Your answer
8. 24/7 alternate agency contact - Phone:
Your answer
9. 24/7 alternate agency contact - E-mail:
Your answer
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