MAT Program Request Form

I am interested in:
Hosting a program at my facilityParticipating in a program in my area

First Name (required)

Last Name (required)

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Street Address line 2

City

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Phone Number (required)

Email (required)

Check the time periods you would be interested in:
July- Sept 2019Oct-Dec 2019Jan-Mar 2020Apr-June 2020

Illinois DocAssist is a service that offers information to healthcare providers regarding the detection, diagnosis and treatment of psychiatric problems in children, adolescents and perinatal women. This service does not consult directly to or about individual patients. While the provider seeking consultation may use this information in making treatment decisions about a particular patient or patients, this consultation is general information only, and should not be construed as direct advice about managing any particular patient's care. If the consultant replies to your question(s) in written form, please understand that the written consultation is intended for the provider ONLY and is NOT intended to be shared directly with a patient or their parent/guardian. Illinois DocAssist consultants have no direct knowledge of the patient, and therefore has not presented the information in a manner that is appropriate for the individual patient's cognitive or emotional processing or the context of the patient's life.

MAT Program Request Form

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