Wufoo

Name * First Last
Title/Position *
Phone Number * ### - ### - ####
Email *
Preferred Method of Contact *

Please indicate the method in which we should contact you.
Name of Medical School, Hospital, or Health System *

Please provide the name of the medical school, hospital, or health system where you plan to implement the ISP.
City, State *
Website
Institution Information

Please answer the following questions about the institution interested in the Interactive Screening Program (ISP)
What type of institution will implement ISP?
Medical School Hospital Health System (i.e., multiple hospitals, hospitals and medical school)
Approximate number of individuals that would be invited to participate in ISP (i.e., medical student/resident enrollment or physician/staff employment for institution) *
If your institution were to use the ISP, who would the Program most likely target? *
Medical Students Residents & Trainees Professional Degree Students Physicians Faculty or Staff Other
Mental Health Services & Clinical Personnel

Required for ISP implementation, mental health services and clinical personnel are provided by the institution - often in partnership with student and/or faculty wellness programs, or physician wellness committees.
Does your institution currently offer mental health services to intended ISP participants (i.e., medical students, residents, physicians, faculty or staff)? *
Yes No
Please describe the services available *
Does your institution currently engage in any mental health outreach to individuals who would be targeted by the ISP? *
Yes No
If YES, please describe briefly
Are counselors available to provide program services? *
Yes No

One full-time or FTE counselor is needed for every 10,000-12,000 program participants to conduct the following program services: review and respond to participant questionnaires and dialogues.
If NO, please describe clinical personnel available to provide program services.
Are the resources currently available for the ISP annual program fee? *
Yes No

Program Fees for Medical Schools:
One-time start-up fee of $2,500.00
Annual License fee of $2,500.00

Program Fees for Hospitals/Health Systems:
One-time start-up fee of $5,000.00
Annual License fee of $5,000.00
If NO, please describe plans to obtain these resources
Additional Information
Please provide any additional information that would help us understand your intended use of the ISP
How did you hear about ISP?
AFSP Website ACGME Resources & Tools Colleague at another institution that utilizes ISP Conference Local AFSP Chapter Local Out of the Darkness Community or Campus Walk Listserv Word of mouth Other
If you heard about ISP at a conference, please let us know which one:
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Wufoo

Institution Information

Mental Health Services & Clinical Personnel

Additional Information