Durham System of Care - Community Collaborator Form

Contact Information

* Name

* Organization/Agency

* Street Address

* Work Phone

* Alternate Phone

* E-Mail Address

* Website URL

Organization/Agency Information

* What is your agency/organization mission?

* Provide an brief overview of your agency's/organization's purpose and population served

* Describe current community initiatives and collaborative involvement

* Describe How you agency/organization aligns with Durham System of Care values and principles.

Interagency Collaboration
Individualized Strengths-Based Care
Community-Based Services
Cultural Competence
Child and Family Involvement
Accountability

Level of Participation

Describe your organization/agency's Current involvement with the Durham Community Collaborative including workgroups and Leadership Roundtable. Specify dates and duration of involvement.

Indicate how your agency/organization will or will continue to contribute to the work of the Durham Community Collaborative. Please check all that your agency/organization can support.

Serve as a liaison between your organization/collaborative and the Durham Community Collaborative at monthly Collaborative meetings

Participate on at least one DCC workgroup (workgroups typically meet once a month or more often as needed)

Integrate your agency/organization workgroup into the Community Collaborative

Supervisor/Mid level manager participation in Leadership Roundtable. LRT meets monthly