BIRCh Sign-Up to Receive Hospital to School Transition Protocol

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Thank you for your interest in our Hospital to School Transition Protocol! We encourage you to view our online learning modules (https://www.umb.edu/birch/online_learning) that will support your implementation of this protocol. Please complete the following demographics and provide your email address at the end of the form and we will share a blank BIRCh Hospital to School Transition Protocol for your use.

What is your role? *

General education teacher

Building level administrator

District level administrator

Special education teacher

School psychologist

School counselor

School social worker

School nurse

Therapist/clinician or administrator at a community agency

Therapist/clinician or administrator at a hospital

Therapist/clinician or administrator at a state agency

Parent

University trainer

Graduate student

Prefer not to say

Other:

What age group do you work with? (check all that apply) *

Early childhood (under age 5)

Kindergarten-5th grade

6th-8th grades

9th-12th grades

Other

Required

What other school-based behavioral health training topics are you interested in receiving training in?

Where do you typically seek out professional development opportunities? *

Building administrator (principal, school leader, etc.)

District administrator

State association (e.g., Massachusetts Association of School Psychologists)

Department of Education or another state agency (e.g., Massachusetts Department of Elementary & Secondary Education, Department of Mental Health)

Community mental health partner (e.g., community service agency, hospital)

Other:

Please provide the zip code(s) where the school/district/organization you work is located. (If you are a graduate student, please report the zip code where you currently reside). *

What is your race? We recognize the reporting categories below do not provide a nuanced view of individuals’ identities. These categories are valuable for comparing information across sources with our partners in the City of Boston. *

American Indian/Alaska Native

Asian

Black or African American

Hispanic/Latinx

Native Hawaiian or other Pacific Islander

White

Multiple races (non Hispanic/Latinx)

Other

Prefer not to say

Required

Additional information you would like to provide about your identity.

How did you hear about this training opportunity? *

Social media

Administrator in your school or district

Colleague

Email listserv from your school or district

Email listserv from a state agency (e.g., DESE)

Other

Required

Please provide your email address below if you are interested in receiving the BIRCh Hospital to School Transition Protocol by email. The BIRCh Project staff will follow up with you by email to ask about your implementation of the protocol for the purpose of us making improvements to the protocol. We will also add your email to the BIRCh Project email list so you can receive updates. Thank you again for your interest! Please follow us on social media (Twitter: @BIRCh_project, Facebook: BIRCh : Behavioral Health Integrated Resources for Children Project). *

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