Consultation Request Form

Thank you for your interest in Educational Consultation Services. Please complete this form to request services. Someone from our team will follow up with you within 1-2 business days.

You may save your work and finish this form within 30 days by using our Save and Continue option, located at the bottom of this form. Our server stores your responses during that time period and you will receive an email with a link to continue.

Full Name(Required)

First Last

Email(Required)

Are you the appropriate primary contact for the administration (to schedule, contact regarding renewal, etc.) of this contract on your end?(Required)

Yes

Contract Primary Contact’s Name(Required)

First Last

Primary Contact’s Email Address(Required)

Your Organization

Name of Organization(Required)

Organization’s Address(Required)

Street Address Address Line 2 City State ZIP Code

Organization’s Website

(if applicable)

How would you classify your organization?(Required)

residential

community mental health

in-patient

out-patient

private practice

educational institution

additional classification not listed

(select all that apply)

Please describe other classification(Required)

What dates and times are you available for consultations?(Required)

What is your time zone?(Required)

What is the age range of the clients you serve?(Required)

Would you like to proceed with a pre-paid or paid-as-utilized contract?(Required)

Pre-paid

Paid-as-utilized

Number of pre-paid hours? (pre-paid contracts require a minimum purchase of 6 hours)(Required)

Please enter a number greater than or equal to 6.

Please list any particular specialties in which you work (e.g. substance use).

Are you wanting to use this consultation for support in preparing for DBT-LBC certification?(Required)

Yes

Possibly

What issues and/or challenges are you looking for consultation to support?(Required)

Contract Information

Please only include the number of people who will be signing the contract (billing contact will be added next).(Required)

Contract Signature Name(Required)

First Last

(additional names will be collected at the bottom of this form)

Email(Required)

Title(Required)

Billing Information

Please provide the name of the person who will provide billing information for the contract.(Required)

First Last

Billing Contact’s Email Address(Required)

Please provide any specific notes and/or information we should include on invoices.

Please share anything else related to your contract, billing, etc. we should be aware of or that needs to be confirmed prior to drafting the contract?

We use a system called Avaza to send invoices. Pre-paid, invoices are sent after we receive an executed contract and must be paid prior to service delivery. Paid-as-utilized we typically bill within one to two weeks of the service date.

Contract Signer #2

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Contract Signer #3

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Contract Signer #4

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Contract Signer #5

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Contract Signer #6

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Contract Signer #7

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Contract Signer #8

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Contract Signer #9

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Contract Signer #10

Please provide the following information for each additional contract signatory.

Name(Required)

First Last

Email(Required)

Title(Required)

Click submit below to enter your responses.

Phone

This field is for validation purposes and should be left unchanged.