Submission Form

Thank you for your interest in sharing what your company is doing to advance mental health. Please fill out the form below to submit your company’s story. A Partnership representative will contact you to follow up.
*Required fields
Contact Information:
First Name:*  
Middle Name:
Last Name:*  
Phone Number:*  
Email Address:*  
 
Company Information:
Company Name:*  
Major Region:* (Hit Shift or Control while selecting to choose more than one item from lists)
Type of Industry:* (Hit Shift or Control while selecting to choose more than one item from lists)
Number of Employees:*  
 
Problem Statement:*
 		 (Describe briefly how your company came to implement this approach)
Outcomes/ROI: (Summarize briefly any results you can share – greater detail can be provided below)
Examples of Mental Health Innovation:
(Please describe your program in detail – methods used, personnel involved, metrics for measurement, participant reactions, outcomes, etc.)
Disability Management:
Disease Management:
Employee Assistance Program:
Evaluation/Metrics:
Health Plans:
Integration: (of internal departments and/or external vendors)
Provider Communication:
Wellness:
Other:
Next Steps/Important Findings:
Website:
Attachments:
(Attach any documents or references that would help readers better understand your programs; e.g., examples of promotional materials, assessment tools, case studies, etc. Attachments cannot be larger than 4MB and must be in Word doc. or PDF format.)

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