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.
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.
Type the main organization your program is a part of. 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.
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.
Enter the address where services are offered.
Complete if this differs from psychical address
Include a link to your agency/program website.
Enter the name, phone number, and email for the primary contact for CONNECT on boarding. This may or may not be the same individual completing this form.
Include all counties where your program primarily offers services. If you offer services statewide, simply type "statewide".
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.
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".
If you selected "Other" in the list above, please provide additional details here.
Enter the information and select the corresponding role(s) for that individual to be using CONNECT for this program.
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 providers the service directly to the client. Includes but is not limited to: Doctor, Nurse, Social Worker, Therapist, etc.
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 providers the service directly to the client. Includes but is not limited to: Doctor, Nurse, Social Worker, Therapist, etc.
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 providers the service directly to the client. Includes but is not limited to: Doctor, Nurse, Social Worker, Therapist, etc.
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 providers the service directly to the client. Includes but is not limited to: Doctor, Nurse, Social Worker, Therapist, etc.
Indicate if additional users are needed for gatekeeper/provider role 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.