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QPR Contact Form
This is REQUIRED to attend a virtual QPR training hosted by North Range Behavioral Health. This information will only be used in the event of an emergency and will be deleted immediately after the training.
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* Indicates required question
Organization and training date (if known):
*
Your answer
Name (first and last)
*
Your answer
Address you will be at during the training (this will only to be used in case of emergencies, no mail will be sent to you and this form will be deleted after the training is complete)
*
Your answer
Direct phone number (this will only to be used in case of emergencies, no mail will be sent to you and this form will be deleted after the training is complete)
*
Your answer
I agree to reach out to facilitator if mental health needs arise during the QPR training. I agree to have facilitator contact me if I leave the training without notice.
*
Yes
No. By selecting no, you will not be allowed to participate in the training.
Required
Do you provide direct mental health service to youth 10-24 years old?
*
Yes
No
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