COMPETITION REGISTRATION
Register for access to the Behavioral Health Integration Innovators Competition entry form. For team registrations, a team lead is required to register. This individual will represent the team and be responsible for the application submission.

You will receive a confirmation email after you have successfully registered. If you do not receive a confirmation email, please check your junk folder. Please note this registration form is case sensitive.

If you experience technical difficulties, please contact jklewitz@tafp.org.

Email address *
TEAM LEAD INFORMATION
First name (team lead) *
Your answer
Last name (team lead) *
Your answer
Designation (MD, DO, LCSW, etc.) *
Your answer
Your position / title at your workplace
Your answer
Your cell phone number
Your answer
TEAM INFORMATION
Team name (you can change this later)
Your answer
Setting-of-care category *
LOCATION INFORMATION
Location name
Your answer
Location address
Your answer
Location city, state, ZIP
Your answer
Location phone number (+ext, if applicable)
Your answer
A copy of your responses will be emailed to the address you provided.
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