NC-PAL REACH PPP Registration

Use this form to request registration for NC-PAL's REACH PPP training program. All pediatric primary care providers in NC are welcome: pediatricians, family physicians, nurse practitioners, and physician assistants. If you have questions about your eligibility, please contact us before registering.

Your Information

First Name

Last Name

Email Address

License Type

Shipping address for training materials

Address

Address 2

City/Town

State

ZIP Code

Are you a health care provider?

Training Preferences

Training Date

Preferred Call Schedule

After the three-day training, the mini-fellowship will continue via virtual case discussions. The case calls will be held on Zoom twice a month for six months. Please indicate your preference for a group call schedule:

Questions	Yes	No	If Need Be
Tuesdays 12pm-1pm	Yes	No	If Need Be
Wednesdays 12pm-1pm	Yes	No	If Need Be
Thursdays 8am-9am	Yes	No	If Need Be
Fridays 12pm-1pm	Yes	No	If Need Be

How did you hear about REACH Training?

Provider Information

Complete these fields for the facility where you most commonly practice.

Practice Name

Address

Address 2

Practice City

Practice County

Practice State

Practice ZIP Code

Area of Specialty

Do you work in a school-based health center?

NC-PAL Enrollment

If you're a clinical provider caring for pediatric, pregnant, or postpartum patients, you can complete your NC-PAL enrollment in one step along with your REACH PPP registration! Enrolling with NC-PAL gives you access to our psychiatry access line as well as training and educational programs.

Enroll in NC-PAL?

By participating in the North Carolina Psychiatry Access Line (NC-PAL):

I agree to inform patients that I may engage the NC-PAL program on their behalf and will share health information with the program in order to assist in care.
I understand that the goal of NC-PAL is to support the management of behavioral health disorders and that care is not transferred to NC-PAL.
I understand that NC-PAL MDs/NPs will not be prescribing medications via the consultation line.
I understand that NC-PAL is to be used for non-emergent clinical questions and not to be used for patients in crisis.
I agree to complete periodic surveys about my use and satisfaction with NC-PAL.

I have read and accept the terms of the NC-PAL agreement.

Once you have submitted this form, you will need to continue from the following page to complete a pre-assessment on SurveyMonkey. Please note that your registration is not complete until you have submitted the pre-assessment!