Date of Request
Type of TA requested: Please check all that apply:
Sequential Intercept Model (SIM) - AdultSIM - Juvenile JusticeCrisis Intervention Team (CIT)Stepping Up InitiativeFacilitation of specific work (please list name- description goes below)Educational WorkshopFitness to Proceed/Aid & AssistUnsure - would like an exploratory conversation with you regarding TAOther (please list)
Description - Please provide a brief description of the item(s) you identified above - including the following in your description:
Goal of your request - what do you want the TA to accomplish?
What are you requesting - Are you requesting a specific workshop like SIMs or are you looking for an educational presentation on a specific topic?
Who is your audience - community meeting, specific agency representatives, number of people if known, etc.
Timeline - when are you wanting this completed by?
Other relevant information