Problem Management Plus Interest Form

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Thank you for your interest in Problem Management Plus. The information provided in this form will be shared with staff members trained in Problem Management Plus (PM+) so they can follow up with the individual interested in utilizing this service.

Referral Source

Please state the name of the person who told you about PM+ services.

Referral Email

Please state the email address of the person who told you about PM+ services.

Name

Please enter the first and last name of the person interested in receiving PM+ services.

Phone Number

Please enter the phone number of the person interested in receiving PM+ services.

Willingness to receive text messages?

Please indicate if the person interested in receiving PM+ services is open to receiving text messages.

Yes

Email Address

Please enter the email address of the person interested in receiving PM+ services.

Zip Code *

Gender *

Man

Woman

Trans man/Transgender Man

Trans woman/Transgender Woman

Non-binary

Prefer not to answer

Other:

Age *

Race *

White

Black or African American

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiracial

Different Identity

Prefer not to answer

Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Problem Management Plus (PM+) is helpful for many different challenges. PM+ is not as helpful when people are experiencing dementia or other forms of cognitive impairment, active suicidal thoughts and feelings, or struggling with a substance use addiction.

Are you experiencing any of these at the moment? Please select all that apply.

Dementia or other forms of cognitive impairment

Active suicidal thoughts or feelings

Substance use addiction

None of the above

Required

Supportive Resources

For anyone who may be experiencing challenges that PM+ may not be helpful in addressing, please utilize the following resources:

Call 988 for the Suicide and Crisis Lifeline
Call 911 for Emergency Assistance
Text “Home” to 741741 for the National Suicide Prevention Lifeline/ Crisis Text Line
Call 800-543-3638 for the LIFENET Hotline
Call 866-488-7386 for the Trevor Project Lifeline (LGBTQ focused support).
Call 1-800-662-HELP (4357) for the Substance Abuse & Mental Health Services Administration's (SAMHSA’s) National Helpline

PM+ is most effective when people attend sessions once per week for 1.5 hours over a 5 week period. Are you able to commit to attending sessions weekly in person or over Zoom over the next 1.5 to 2 months?
*

Yes

Maybe

Preferred Contact Date and Time

Please select three (3) dates and times within the next week that a PM+ Helper can contact the person interested in receiving PM+ services for follow-up.

Morning (9 am-11:30 am)

Afternoon (12 pm- 3:30 pm)

Early Evening (4 pm- 6:30 pm)

Monday

Tuesday

Wednesday

Thursday

Friday

Additional Notes *

Submit

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