Partner Site Application

This form is for organizations interested in becoming a Mental Health Community Partner Site.

Agency Name

Contact Person Information

Agency Website

First Name

Last Name

Job Title

Phone

Mailing Address

Address Line 1

Address Line 2

County

City

State

Zip Code

Country

NYS Counties Served

MHCP Services Provided

In-person Hybrid Online

How many individuals from your agency would you like to have certified as Mental Health Community Partners?

Describe how you plan to use Mental Health Community Partners at your agency or private practice.

Please describe key communities/populations served and specific programs/services offered at your agency (e.g. services for students, immigrants/refugees, LGBTQ+ community, veterans, justice-involved individuals, faith communities, disability community, healthcare, substance use, crisis response, housing, workforce, etc.)

Please check below to accept.

Upon acceptance as a Partner Site, agency leadership will be required to sign a Memorandum of Understanding stipulating commitment to training selected staff and offering the program to the local community. Staff participation in the training will also be contingent upon submission and approval of their Mental Health Community Partner application.