| Truusight

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

Implementation Project Number (you can find this in the email with the form link)

Super User First Name

Super User Last Name

Super User Title

Super User Email

Super User Phone

Additional Usernames: (HR, EAP, etc.)

User 1 First Name

User 1 Last Name

User 1 Title

User 1 Email

User 1 Phone

User 2 First Name

User 2 Last Name

User 2 Title

User 2 Email

User 2 Phone

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

IT Point of Contact First Name

IT Point of Contact Last Name

IT Point of Contact Title

IT Point of Contact Email

IT Point of Contact Phone

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)

Community 1 Name

Community 1 types of services offered

First Name

Last Name

Website

Phone

Community 2 Name

Community 2 types of services offered

First Name

Last Name

Website

Phone

Community 3 Name

Community 3 types of services offered

First Name

Last Name

Website

Phone

Community 4 Name

Community 4 types of services offered

First Name

Last Name

Website

Phone

Completed By:

Name

Date

If you are human, leave this field blank.

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:

Co-Founder, Jeff Sepesi’s Personal Story