TA/Training Request Form for the Crisis and Recovery Enhancement (CARE) TA Center Please fill out the form below if you would like to request trainings, technical assistance (TA), or consultation services. Tell us how we can help your local efforts to strengthen behavioral health care coordination, criminal justice diversion, and the crisis care continuum, including for youth and people experiencing homelessness. The CARE TA Center supports Mental Health Services Act (MHSA)-funded community and county level programs including, but not limited to, county mental health departments, local mental health boards and commissions, community-based organizations (CBOs), and other key service agencies. First Name*Last Name*Title or Role*Organization*City*Zip Code*CountyAlamedaAlpineAmadorButteCalaverasColusaContra CostaDel NorteEl DoradoFresnoGlennHumboldtImperialInyoKernKingsLakeLassenLos AngelesMaderaMarinMariposaMendocinoMercedModocMonoMontereyNapaNevadaOrangePlacerPlumasRiversideSacramentoSan BenitoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis ObispoSan MateoSanta BarbaraSanta ClaraSanta CruzShastaSierraSiskiyouSolanoSonomaStanislausSutterTehamaTrinityTulareTuolumneVenturaYoloYubaStateCaliforniaPhone*Email* Website A. About Your Organization1. Is the requesting organization an MHSA-funded county office or community-based provider for the crisis continuum or justice diversion services?*(Select one)YesNoNot Sure2. Will the requesting organization (applicant) be receiving the TA/training services directly?*(Select one)YesNoMultiple organizations will receive services3. Please check the categories that best describe your organization:*(Select all that apply) County BH/MH office County Dept. (other) County AOD/MH, Prevention Provider City Agency State Agency Law Enforcement Religious Organization Clinic/Community Health Center Hospital/Health Service Community Based Org, 501(c) 3 School (k-12) College Business (private) Coalition/Community Partnership Other 3a. If Other, please describe:4. How did you hear about CARE TA services?(Select all that apply) Workshops/Brochure County MHSA-funded program Dept. of Health Care Services (DHCS) Colleague Previous Utilization Regional Trainers Consultant Internet Other 5. Have you ever received TA/training services through a DHCS funded contract?(Select one)YesNoB. TECHNICAL ASSISTANCE INFORMATION6. What kind of assistance is needed?*(Select all that apply) Professional Competency Training Customized Training Consultation Facilitation Product Development Information Referral 7. Please describe the problem/issue that your organization seeks to address through this technical assistance or training (please note if this is a continuation of a previously received TA assignment).*8. What are the specific outcomes to be achieved as a result of receiving technical assistance or training?8a.8b.8c.9. Do you have a proposed timeline for the start of requested TA?*(Select one)YesNo9a. Please enter date here:* Date Format: MM slash DD slash YYYY 10. Approximately how many individuals will participate in the TA or training service?11. Are there any cultural and/or linguistic needs regarding your community, organization or program participants that you would like addressed in this TA?*(Select one)YesNo11a. If yes please describe*12. Where will TA/training service occur?13. Are you requesting a specific consultant?*(Select one)YesNo13a. If yes please list here*
