el Centro STAR en español

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Technical Assistance Request

Please complete the form below to submit your request to the STAR Center:

Your Name*:

Organization:

Address Line 1:

Address Line 2:

City:

State:

Zip Code:

Phone*:

FAX:

E-mail address*:

Web site:

Please select all that apply:

I am a:
Consumer
Family Member
Academic (teacher, researcher, student)
Other:
My organization is:
Consumer-run organization or group
State, county or local mental health authority
Federal government agency
Academic institution
Provider organization
Media
Other:
Type of technical assistance requested:
Verbal information
Materials
Referrals
Training
Consultant
Other:

Additional Information:

 

*Required

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