FREE CME
CME - OPIOID EPIDEMIC
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FORMS
Improved Intake Form for Consulting Services
Business Information
Business Name: __________________________
Industry/Field: __________________________
Contact Person: __________________________
Position/Title: __________________________
Business Address: __________________________
Phone Number: __________________________
Email Address: __________________________
Preferred Method of Contact (Phone/Email): __________
Project Details
Project Title/Name (if applicable): __________________________
Briefly describe your current educational and/or health management programs (if any):
What are your specific goals for this consulting project?
Who is your target audience? (Employees, Management, Community, etc.)
What are your expected outcomes or desired results from this project?
Project Scope and Requirements
What specific areas of focus are you most interested in? (e.g., Chronic Pain Management, Opioid Alternatives, Employee Wellness)
What are the primary challenges or concerns you're facing in relation to these areas?
What is your timeline for completing this project?
Start Date: __________ End Date: __________
What is your budget for this project?
Available Budget: $______________
What format of deliverables do you prefer? (Workshops, Webinars, Documentation, etc.)
Additional Information
Have you previously implemented any initiatives or programs related to chronic pain management or opioid alternatives?
Are there any key stakeholders or partners involved in this project?
How did you hear about our consulting services?
Consent and Confirmation
By submitting this form, you consent to being contacted and for your information to be used for the consulting project.
[ ] Yes, I consent.
[ ] No, I do not consent.
Signature: __________________________ Date: __________
Submit Button (for online forms) or Instruction to Return Completed Form (for paper forms)