UNM CBH Request for Service/Consultation/Technical Assistance




Community/Organization Name:    

Contact Information:




Mailing Address:

Please click the most appropriate box for the type of services you are requesting:

  •   Evaluation/Research
  •   Clinical
  •   Training
  •   Technical Assistance/Systems Consultation

Briefly describe the type of support you are requesting in one paragraph:

Type of Support:

What is the timeframe for your request? Please click the most appropriate box:

  •   Within the next month
  •   Within the next 3 months
  •   Within the next 6 months
  •   Within this year
  •   Other

If "Other", please explain:

List any other community partners that would/should be involved?

Community Partners:

If you have already been in touch with a member of our center staff please include their name:

Staff Contact:

If you have any questions or problems with this form, please call CBH: 505.272.6238.