Thank you for your interest in having your company's approach to mental health included in our database. Please fill out the following information. A Partnership representative will call you after your form has been submitted.
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| *Required fields
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| Contact Information: |
| First Name:* |
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| Middle Name: |
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| Last Name:* |
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| Phone Number:* |
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| Email Address:* |
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| Company Information: |
| Company Name:* |
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| Major Region:* |
(Hit Shift or Control while selecting to choose more than
one item from lists)
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| Type of Industry:* |
(Hit Shift or Control while selecting to choose more than
one item from lists)
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| Number of Employees:* |
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Problem Statement:*
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(Describe briefly how your company came to implement this approach) |
| Outcomes/ROI: |
(Summarize briefly any results you can share – greater detail can be provided
below) |
Examples of Mental Health Innovation:
(Please describe your program in detail – methods used, personnel involved,
metrics for measurement, participant reactions, outcomes, etc.) |
| Disability Management: |
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| Disease Management: |
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| Employee Assistance Program: |
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| Evaluation/Metrics: |
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| Health Plans: |
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| Integration: (of internal departments &/or external vendors) |
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| Provider Communication: |
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| Wellness: |
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| Other: |
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| Next Steps/Important Findings: |
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| Attachments: |
(Attach any documents, or references that would help readers better understand
your programs; e.g., examples of promotional materials, assessments,
descriptions of awards received, case studies, etc. must be in Word doc. or PDF form. No larger than 4MB) |
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