Request For Technical Assistance

	SUBSTANCE ABUSE SERVICES REQUEST FOR TECHNICAL ASSISTANCE	Please complete and submit this form to: ODMHSAS Attn: Armisha Harrison P.O. Box 53277 Oklahoma City, OK 73152 fax to: 405-522-3767 or email: aharrison@odmhsas.org
Section 1. to be completed by provider

Date:	Name: Title:	Contact Source #: Program Title:
Agency:		Phone:
Address:		Fax:
City: State: Zip:		Email:
Signature:		Date:

Section 2.
Type of technical assistance requested by provider: Programmatic Medicaid Clinical Drug Court Administrative Case Management		Techincal Assistance Referral Source: Provider/Self-Referral On Site Review Other:

Section 3.
1) Describe the specific areas in which you are requesting technical assistance:
[Examples: how to recruit staff with special skills; how to get a program started (or restarted); how to implement performance measures; how to identify new clients/perform successful outreach; how to do treatment planning and documentation; techniques for successful case management programs; Medicaid documentation, claims, and billing.]

2) Describe what you would like to accomplish (long or short-term goal) by receiving this technical assistance:
[Examples: improve evaluation/client outcomes, increase effectiveness of program curricula and treatment model]

Section 4.
Please select the type of technical assistance that would best address your needs by checking the appropriate box(es).
Individual Technical Assistance: Callor Correspondence On site visit* *Estimate three potential dates over the next three months your organization may be prepared to receive a technical assistance visit.		Specialized Training: Specialized training offered state-wide Topic: At ODMHSAS office in Oklahoma City Topic: