Consultation Services Request Consultation Services Request Form Thank you for your interest in Educational Consultation Services. Please complete this form to request services. Someone from our team will follow up with you within 1-2 business days. You may save your work and finish this form within 30 days by using our Save and Continue option, located at the bottom of this form. Our server stores your responses during that time period and you will receive an email with a link to continue. Full Name(Required) First Last Email(Required) Are you the appropriate primary contact for the administration (to schedule, contact regarding renewal, etc.) of this contract on your end?(Required) Yes No Contract Primary Contact’s Name(Required) First Last Primary Contact’s Email Address(Required) Your OrganizationName of Organization(Required) Organization’s Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Organization’s Website (if applicable)How would you classify your organization?(Required) residential community mental health in-patient out-patient private practice educational institution additional classification not listed (select all that apply)Please describe other classification(Required) What dates and times are you available for consultations?(Required)What is your time zone?(Required)Hawaii Standard TimeAlaska Standard TimePacific Standard TimePhoenix Standard TimeMountain Standard TimeCentral Standard TimeEastern Standard TimePuerto Rico and US Virgin Islands TimeCanada Newfoundland TimeArgentina Standard TimeBrazil Eastern TimeCentral African TimeGreenwich Mean TimeUniversal Coordinated TimeEuropean Central TimeWhat is the age range of the clients you serve?(Required) Would you like to proceed with a pre-paid or paid-as-utilized contract?(Required) Pre-paid Paid-as-utilized Number of pre-paid hours? (pre-paid contracts require a minimum purchase of 6 hours)(Required)Please enter a number greater than or equal to 6.Please list any particular specialties in which you work (e.g. substance use).Are you wanting to use this consultation for support in preparing for DBT-LBC certification?(Required) Yes No Possibly What issues and/or challenges are you looking for consultation to support?(Required)Contract InformationPlease only include the number of people who will be signing the contract (billing contact will be added next).(Required)12345678910Contract Signature Name(Required) First Last (additional names will be collected at the bottom of this form)Email(Required) Title(Required) Billing InformationPlease provide the name of the person who will provide billing information for the contract.(Required) First Last Billing Contact’s Email Address(Required) Please provide any specific notes and/or information we should include on invoices. Please share anything else related to your contract, billing, etc. we should be aware of or that needs to be confirmed prior to drafting the contract? We use a system called Avaza to send invoices. Pre-paid, invoices are sent after we receive an executed contract and must be paid prior to service delivery. Paid-as-utilized we typically bill within one to two weeks of the service date.Contract Signer #2Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Contract Signer #3Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Contract Signer #4Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Contract Signer #5Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Contract Signer #6Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Contract Signer #7Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Contract Signer #8Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Contract Signer #9Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Contract Signer #10Please provide the following information for each additional contract signatory. Name(Required) First Last Email(Required) Title(Required) Click submit below to enter your responses. CommentsThis field is for validation purposes and should be left unchanged.
