Technical Assistance | Culture Connections

Initial Consultation Request Form

Technical assistance is offered free of charge to DMHAS-funded mental health agencies and self-help centers in the following northern New Jersey counties: Bergen, Essex, Hudson, Hunterdon, Morris, Passaic, Somerset, Sussex, and Warren.
For a list of eligible agencies by county, please click here.

Agency Name:

Please provide the following information for the person who is completing this form:

Your Name:

Your Position:

Your Phone Number:

Your Email:

Address for initial consultation and any essential driving directions or parking instructions:

We ask that at least one individual at the meeting is from the agency’s executive leadership (i.e. Executive Director, Chief Executive Officer, President, Chief of Operations, Vice President, etc.) Please provide the name and position of this individual:
Name:
Position:

Please provide the name and position of additional anticipated attendees.
Name:
Position:
Name:
Position:
Name:
Position:
Additional Attendees:

Requested Dates/Times for initial consultation (please allow up to one hour):
First Choice:
Date:
Time:

Second Choice:
Date:
Time:

Third Choice:
Date:
Time:

Please enter the following word image into the box below. The letters are case sensitive. Do not include spaces.

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