St. Louis CRUSH Coalition Member Registration

Name*

Name of the Agency You Represent*

Position*

Email*

Phone Number*

What services does your agency provide to the community?*

Medical Stabilization

Acute Psychiatric Care

Clinically Managed Residential

Medically Managed Residential

Partial Hospitalization Program

Intensive Outpatient

Outpatient

Peer Support

Recovery Community Center

Harm Reduction Services or Street Outreach

Recovery Residence

First Responder

Prevention or Education

Outpatient Methadone or Suboxone

Health Department or Violence Prevention

Hospital

Private Practice

Other

What types of insurance or payment methods are accepted at your agency?*

None- Grant funded or you do not bill

Private Pay

Most Private Health Insurance

Most Marketplace Insurance

Opportunities for 80-100% Financial Assistance

Medicaid

Managed Medicaid

Medicare

Other

Would you like to attend other agencies' events with the St. Louis CRUSH Coalition?*

Yes

No

Would you like to attend St. Louis CRUSH's events?*

Yes

No

The St. Louis CRUSH Coalition meetings are scheduled to take place the second Monday of every month. Are you able to attend our virtual and in-person monthly meetings?*

Yes

No

Sometimes

I agree to receive emails from the St. Louis CRUSH Coalition in regard to monthly meetings, partner updates, and events.

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