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Request Primary Care Materials

Please complete and submit this form in order to receive TeenScreen Primary Care's Quick Start Guide for implementing mental health checkups in your practice. The (*) symbol denotes fields that are required.
Please note, these materials are designed for screening in primary care, medical and mental health settings only. If you are interested in screening in school or community-based locations, please click here.

Formal Title (*)
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Name (*)
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Title (*)
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Credentials (*)
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Company/ Practice (*)
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Address (*)
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City (*)
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State (*)
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Zip (*)
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County (*)
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Phone (*)
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E-mail Address
(*)
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Please check the box that best describes your affiliation (check all that apply):
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How did you hear about our efforts?
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Please choose the Pocket Guide & screening questionnaire you would like to receive (please only select one):
(*)

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In addition to the Pocket Guide, we will also send you copies of the "What's on Your Mind" teen brochure that contains a copy of the screening questionnaire inside of it. How many copies of the brochure would you like (note, the limit for brochures is 100 at a time)?
(*)
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Please check the primary reason you would like to receive these materials.
(*)


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Other Provider and Patient Demographic Information
(these items are not-required to submit this form)
Please check the box that best describes the setting in which you are interested in developing a screening program (check all that apply):






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How many patients do you plan to offer mental health checkups to over the course of the next year?
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Is there anything else that you would like to tell us about yourself or your area of interest?
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