Care Coordination Training Application Questions

Name

First NameLast Name

Position Title

Email

example@example.com

Job Catagory (please select all that apply)

Setting (please select all that apply)

Organization Name

Organization Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Organization Website

Please select one of the following options:

Please indicate which sessions you are registering for by checking the appropriate column:

Rows	Planning to Attend	Not attending/ Not sure
Nov 05, 2026: Required in-person kickoff*: Collaboration to Support Children and Youth with Special Health Care Needs
Dec 03, 2026- virtual: Family Centered Care
Jan 07, 2027- virtual: Family Engagement and Communication
Feb 04, 2027- in person: Cultural Competency
Mar 04, 2027- virtual:Families as Peers & Leaders
Apr 01, 2027- virtual: System Navigation: Early Childhood & Special Education Services
May 06, 2027- in person: System Navigation: Understanding SDOH Resources
Jun 03, 2027- virtual: Topic of most emerging need identified by participants throughout program**
Jul 01, 2027- virtual: Topic of most emerging need identified by participants throughout program**

*Persons interested in the training program but unable to attend the kickoff meeting can reach out to Marije Thomas at mthomas@ctc-ri.org

**Topics for final two sessions will be determined by learners participating in the Care Coordination Community of Practice Training Program based on session feedback, care coordinator learning needs and emerging issues of children and youth with special health care needs and their families.

Do you have recommendations for topics or sessions?

Acknowledgement

By registering, you conﬁrm your acknowledgement and consent to participate in our Care Coordinator Training Program Community of Practice.

Participants and agree to:

Participate collegially and actively engage in regularly scheduled sessions, including sharing resources, providing comments and feedback, and asking relevant questions
Safeguard patient and client confidentiality by ensuring case presentations will not include identifiable information. Participants will keep any patient information inadvertently provided by participants, or presenters during a session conﬁdential.
Complete periodic surveys and evaluations after each as part of our quality improvement process.
Be solely responsible for the treatment of your patients and understand that all clinical decisions rest with you regardless of recommendations provided by other participants
Only participants who complete the Full Participation requirements stated above including evaluation feedback will be eligible for the $250 stipend.

By registering, you conﬁrm your acknowledgment and consent to participate as a participant/member of your organization (please select both):

For questions, please contact Marije Thomas, mthomas@ctc-ri.org

Care Coordination Training Program/Community of Practice Application Questions