The Community Resource User Form

Please complete this form so we can schedule training for your organization.

Key Terms:
Preferred Partner – Your Organization Information.
Community Partners– Select free or reduced-cost CBOs/Health Systems/ Local or Regional healthcare providers with whom Preferred Partners would like added under their organization.
Super User– Employer Champions.  User with access to inbound and outbound referrals with reporting options. Responsible for providing front-line user support.
IT Point of Contact– Contact for Widget Deployment on Employer website.
Community Partner Users – Users with access to accepting and making referrals.

Preferred Partner Form

Preferred Partner Information

Additional Usernames: (HR, EAP, etc.)

IT Point of Contact - Contact for Widget Deployment on organization's website

Community Partners - Community-Based Organizations (CBOs), Health Systems, Local or Regional Healthcare Providers that you currently partner with for community-based services. (Max 6, Minimum 4)

Completed By: