Registration-Treatment Planning for Person-Centered Care

Please complete the following; an (*) indicates the field is required. At the end of the form, click the Submit button. A confirmation e-mail will be immediately sent to the e-mail provided.

Questions? Please contact the Optum Network Services team at nynetworkmanagement@optum.com.

Organization Name *

Program Name *

Tax Identification Number (TIN) *

Organization Phone Number *

City *

County *

State *

Zip/Postal Code *

Is your organization part of the Optum* provider network *

Please note: Registration preference will be given to participating providers of the Optum network. *United Behavioral Health operating under the brand Optum.

Yes

Unsure

First Name *

Last Name *

License Type *

Title/Position *

E-mail *

E-mail Confirmation *

Phone Number *

This information will only be used to notify you in case of venue issues and will not be used for marketing purposes.

If you have special accessibility, accommodation or dietary needs, please describe

Do you have any prior training or experience with Person-Centered Planning *

Yes

Mental health issues *

Substance use disorders *

Mental health and substance use co-occurring *

Other (please explain)

Children *

Adolescents *

Adults *

Families *

Please provide a response below to indicate if you will be able to attend all three days *

*Technical assistance will help organizations integrate the person-centered approach and may include the following topics: Discuss progress with the implementation of person-centered recovery planning at each organization Identify and discuss any barriers (clinical or administrative) to implementation Share examples of how organizations have engaged recipients of care in the process of planning Address any difficulties in writing person-centered goals, objectives, and interventions Answer questions related to meeting medical necessity criteria

I will attend both days of the in-person workshop and also the 1-day follow-up event on July 15, 2015.

I will attend both days of the in-person workshop but I am not likely to return for the 1-day follow-up event on July 15, 2015.

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Registration-Treatment Planning for Person-Centered Care