IntakeTicket

1. Community Member Name*

3. Phone Number*

4. Email Address*

5. For which type of entity are you seeking technical assistance?*Coalition/Community GroupFaith-Based OrganizationFor-profit OrganizationNon-profit OrganizationOther (please specify below)

6. What community/county is your organization/coalition/self located in? If your organization/coalition/self serve(s) multiple communities/counties, please list each one.*

7. What Illinois Department of Human Services (IDHS) Region is your organization/coalition/self located in?*

8. Does your organization/coalition/self currently receive local, state, or federal funding? If so, what type of funding do you receive?*YesNo

9. What sector(s) does your organization/coalition/self represent? Please select all that apply.*HealthcareSchool(s)Substance Use OrganizationYouth Serving OrganizationMediaLaw EnforcementLocal BusinessState/Local GovernmentMental Health OrganizationOther (please specify below)

10. What type of technical assistance are you seeking from the Center for Community Engagement (CCE) team? Please select all that apply.*TrainingsStrategic Planning AssistanceDeveloping Community Health Needs AssessmentsMarketing Your Organization/CoalitionHow to Apply for Funding/Funding OpportunitiesLearning More About Recovery Oriented Systems of Care (ROSC) CouncilsImplementing Effective MeetingsEstablishing Community Engagement/SuccessBecoming a Certified Recovery CongregationOther (please specify below)

11. If interested in the CCE team providing trainings to your community, please select which trainings you would be interested in receiving. Please select all that apply.*Community Organizing and EngagementStrategic Prevention Framework (SPF)Strategic PlanningSubstance Use Stigma 101Mental Health 101Trauma Informed CareFaith-based trainingsOther (please specify below)

12. Please provide any additional pertinent information that the CCE team should know.

(All questions with an asterisk* require an answer)

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Center for Community Engagement Technical Assistance Intake Ticket