Thank you for your interest in the Systems of Care program. This form can be used for one-time TA questions and inquiries by all stakeholders. It also is the form for the coaching program available to our SOR2 Systems of Care counties. Practices in Marin, San Bernardino, Santa Barbara, Santa Cruz, Siskiyou, and Yolo counties are eligible for to apply for ongoing coaching. If you are applying for ongoing coaching, we recommend that you coordinate with your practice, and have just one person from your team complete the application in order to streamline the process. After you submit the form, an HMA team member will be in touch.

Personal info

Your name

Your email

Your role/title

Organization info

Your organization

Main info

What type of technical assistance are you interested in receiving? (required)

One time or brief consultation with a subject matter expert

Regular coaching with a subject matter expert as described at the Process Improvement Event

Other

Which statement best describes your practice and your interest in technical assistance (coaching)? (required)

Our practice or facility offers Medication Assisted Treatment (MAT) Our practice does not current offer MAT, but we are interested in learning more about MAT and possibly offering MAT in the near future Our practice does not offer MAT, and we do not plan to offer MAT Unsure or prefer not to answer at this time

Are you or your organization participating in other SOR initiatives? (required)

Select all that apply.

County Touchpoints MAT Access Point grant from the Sierra Foundation California Bridge The California Hub and Spoke System for MAT Expansion – Hub The California Hub and Spoke System for MAT Expansion - Spoke MAT in Jails and Drug Courts Center for Care Innovations – Primary Care Center for Care Innovations – Community Partnerships Youth Opioid Response project Not sure

Use this space for any other comments or questions.

An HMA team member will be in touch with you shortly.

Comments or questions

Did you or your organization attend the Process Improvement Event in your county? (required)

Yes No Not sure

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