Consultation Intake Form

What is the name of your organization?(Required)

Please provide your organization's website.

How would you classify your organization?(Required)

Residential, community mental health, in-patient, out-patient, private practice, etc...

What dates and time work best for you?(Required)

 Please provide as many options as possible for the highest likelihood of being matched with a consultant. Please also note that contracts start at least 2-3 weeks after we receive a signed copy of the contract, so when looking at dates and times, we recommend looking at least 3 weeks out.

What time zone are you located?(Required)

Is your work/case in particular speciality (e.g. substance use)?(Required)

Please list all that are applicable.

What is the age range of the population you serve?(Required)

Are you wanting to use this consultation for support in preparing for DBT-LBC certification?(Required)

Yes

What kind of contract would you prefer?(Required)

Pre-Paid

Pay-as-Utilized

When would you like your contract to start?(Required)

As a reminder, your contract will expire 12 months after this date, and if it is pre-paid, will require payment before services can be rendered.

How many pre-paid hours (6 hour minimum)?(Required)

What issues and/or challenges are you looking for consultation to support?(Required)

Are there any specific notes and/or information we should include on invoices?

Contract Recipient

Contract Recipient Name(Required)

First Last

Contract Organization Name (if applicable)(Required)

Only enter if the contract should be between BTECH and this organization.

Contract Recipient Email(Required)

Contract Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contract Signatory/Signatories

Full Name and Email for Each Signatory(Required)

Billing Information Provider

Billing Name(Required)

First Last

Billing Email(Required)

Primary Contacts

Primary Contact Name(Required)

First Last

This is the person that will manage scheduling and contract renewal.

Primary Contact Email(Required)

Team Lead Name

First Last

Team Lead Email

We use Quickbooks 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 are typically billed on a weekly basis.

Is there anything else related to your contract, billing, etc... we should be aware of or that needs to be confirmed prior to drafting the contract?

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