CONNECT Program Sign Up

Complete the form below to initiate the process for signing up your program in the CONNECT System. Upon receipt of a completed form, your local regional administrator will make contact with your organization to set up next steps. Please allow up to five (5) business days for a reply.

Below is also a list of suggested steps to take in order to ensure your program is best prepared to use CONNECT.

1.) Become familiar with how the CONNECT Referral System functions.

This can be done by observing a live demonstration of the system, or the prerecorded version here. It is also recommended that new users engage in the CONNECT demo site to get a “feel” for using the system themselves. Head to our training resources page here to gain access to the CONNECT demo site.

2.) Review the CONNECT Memorandum of Understanding and client Release of Information PDF’s.

The MOU will require electronic signature by each individual user, as well as signature for each program operating in the CONNECT system. Ensure that whomever has signatory authority within your program reviews and consents to the MOU. The ROI is what is signed by each client in the CONNECT system.

3.) Become aware of which region(s) your program resides in by viewing the State of Montana Chronic Disease Bureau’s Regional Map.

Click here to view a map of the current regions.

4.) Prepare a list of external programs and providers where your program frequently sends and/or receives referrals from.

This information will be needed to complete the “referral mapping” section. Referral mapping allows us to make contact with your partner programs at a future date, to promote the use of the CONNECT system.

5.) Have all of your programs information ready when completing this form.

This includes but is not limited to: a description of services offered, details on your current referral process, insurance taken, and whom will be your programs Gatekeeper and Provider(s). Each field marked with a red asterisk is required.

Name of the individual completing this form
If you were directed to complete this form by a system administrator (Regional CONNECT Coordinator, Prevention Specialist, etc.) please put their name here. Type "N/A" if you weren't directed here by a system administrator.
Type the main organization your program is a part of. Use the example text as a guide only.
Enter the name of your program, as it should be displayed in CONNECT. If you are operating out of a multi-program organization, each program will need to be added individual. Use the example text as a guide only.
Include a thorough description of your program. This will be included in CONNECT to provide an overview of your program. Use the example text as a guide only.
Select the region where your program ans services are physically located. Refer to number "3" in the points above this form to find your numeric region.
Enter in name of main contact for this program.
Enter the email of main contact for this program.
Enter the phone number of main contact for this program.
Enter the fax number of main contact for this program.
Enter the complete and full address where services are offered.
Complete if this differs from psychical address
Include a link to your agency/program website.
Select the population(s) your programs offers services for. If your program has not received specialty training or funding to serve a unique population, you may only select "general population".
If you selected "Other" in the list above, please provide additional details here.
Select all applicable fields for the service(s) your program offers.
If you selected "Other Services" in the list above, please provide additional details here.
Include all counties where your program primarily offers services. If you offer services statewide, simply type "statewide".
What programs can send your program referrals in CONNECT? Selecting "All" will allow all other programs in CONNECT to send referrals to your program. All is the most common option. Selecting "Some" allows you to specify which programs can send you referrals in the system. This option is selected for programs that may have restrictions on the types of clients they can serve. For example: if your program can only accept court appointed referrals, you would select "Some" and list the court district(s) in CONNECT you can accept referrals from. Selecting "None" will not allow other CONNECT programs to send you referrals. This will set your program up as only able to send client referrals. Your programs answer to this question can be changed at any time by your Gatekeeper.
Enter the information and select the corresponding role(s) for that individual to be using CONNECT for this program. Name and email address are required.
Role Definitions: Gatekeeper: Individual responsible to signing the programs MOU in CONNECT as well as the receiving and assigning of all incoming referrals. Provider: The individual(s) whom provides the service directly to the client. Includes but is not limited to: Doctor, Nurse, Social Worker, Therapist, etc. EES User: Allow access to the experiences and expression screener for youth. All CONNECT account must have at least 1 Gatekeeper and 1 Provider in order to function. These 2 roles may be assigned to the same user.
Role Definitions: Gatekeeper: Individual responsible to signing the programs MOU in CONNECT as well as the receiving and assigning of all incoming referrals. Provider: The individual(s) whom provides the service directly to the client. Includes but is not limited to: Doctor, Nurse, Social Worker, Therapist, etc. EES User: Allow access to the experiences and expression screener for youth.
Role Definitions: Gatekeeper: Individual responsible to signing the programs MOU in CONNECT as well as the receiving and assigning of all incoming referrals. Provider: The individual(s) whom provides the service directly to the client. Includes but is not limited to: Doctor, Nurse, Social Worker, Therapist, etc. EES User: Allow access to the experiences and expression screener for youth.
Role Definitions: Gatekeeper: Individual responsible to signing the programs MOU in CONNECT as well as the receiving and assigning of all incoming referrals. Provider: The individual(s) whom provides the service directly to the client. Includes but is not limited to: Doctor, Nurse, Social Worker, Therapist, etc. EES User: Allow access to the experiences and expression screener for youth.
Indicate if additional users are needed for gatekeeper/provider/EES roles in this program. Additional users are able to be added at any point.
Include the organization name and address. Use the example text as a guide only.
Do you have a contact person at this organization that would be a good contact for on-boarding into the CONNECT System? List there information here.
Include the best contact information for the individual listed above.
Include the organization name and address. Use the example text as a guide only.
Do you have a contact person at this organization that would be a good contact for on-boarding into the CONNECT System? List there information here.
Include the best contact information for the individual listed above.
What method does your organization currently use to send referrals? What is the process to receive referrals? For example, note how incoming/outgoing referrals occur: via phone, fax, web, brochure, business card, paper form, etc. Use example text as a guide only.
Include an estimate of how many referrals your organization sends on a monthly basis
Include an estimate of how many referrals your organization recieves on a monthly basis
Include a narrative on how your program currently tracks referrals. Be sure to include any tools used to track this process. If your program does not currently track referrals, please state that fact.
Include the number of referrals your program receives in a month and how many of those referral your program is able to connect with and serve. If you use a tracking software, please be as accurate as possible. If you do not currently track this- provide an estimate.
Include the number of referrals your program sends in a month and how many of those referrals your program is able to confirm received external services. If you use a tracking software, please be as accurate as possible. If you do not currently track this- provide an estimate.