Section 1 of 1
Request for Community-Based Technical Assistance
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Primary Lead/Contact (First Name, Last Name)
Primary Lead/Contact (First Name, Last Name)
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Lead's Phone Number
Lead's Phone Number
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Organization Location (City, State)
Organization Location (City, State)
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Please share your organization's webpage (if available).
Please share your organization's webpage (if available).
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What term most closely describes your location?
What term most closely describes your location?
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Rural
Suburban
Urban
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Please provide an overview of your organization including the services that you provide.
Please provide an overview of your organization including the services that you provide.
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Are your requesting assistance for an existing coalition or organization or are you just getting started?
Are your requesting assistance for an existing coalition or organization or are you just getting started?
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Existing Coalition
Getting Started
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Please describe your organization's strengths and the extent to which your organization is motivated to make changes, willing to commit time, resources and assets to implementing change, and ability to sustain and support identified changes.
Please describe your organization's strengths and the extent to which your organization is motivated to make changes, willing to commit time, resources and assets to implementing change, and ability to sustain and support identified changes.
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Please describe your technical assistance needs and any barriers or challenges you may be facing.
Please describe your technical assistance needs and any barriers or challenges you may be facing.
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What area do you want to focus on? Please check all that apply.
What area do you want to focus on? Please check all that apply.
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Family Support and Outreach
Prevention
Public Awareness
Prescriptions and Medical Response
Law Enforcement and Criminal Justice
Specific Populations
Partnerships and Systems Change
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How did you hear about us?
How did you hear about us?
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