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Title IV-E Waiver Mental Health Registration Form
This form is for mental health providers to REGISTER for access to a data form to enter trauma screening and treatment data for children in the child welfare system who are being screened under the Title IV-E Waiver efforts.
At which Mental Health Center do you work?
If you are a private provider, please list the name of your practice or clinic.
Your answer
For which county or counties do you take Title IV-E Waiver referrals? (check all that apply)
Required
Please list the primary email address who will need access to this form.
Your answer
Please list an additional email address who will need access to this form, if applicable.
Your answer
Please list an additional email address who will need access to this form, if applicable.
Your answer
Please list an additional email address who will need access to this form, if applicable.
Your answer
Please list an additional email address who will need access to this form, if applicable.
Your answer
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