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LAMMHA Implementation Site Application Form

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Welcome to the Los Angeles Maternal Mental Health Access (LAMMHA) application form - thank you for your interest!

Application to LAMMHA is on a per site basis. Health Centers are encouraged to apply for more than one site location. Any site that serves prenatal patients, pediatrics patients, and/or patients up to 1 year postpartum is eligible to apply. The application takes 5-10 minutes to complete per site once you have the needed clinic data on hand. You may save and come back later to complete. You may tab to the next entry field and use reset to clear your response to an individual question. A code is provided after submission for you to return to your application response.

Please see attached copy of the CCALAC LAMMHA sub-recipient agreement for review. A fully executed agreeement is required for particiaption.

LAMMHA Sub-Recipient Agreement_Cohort 4.pdf

If you have any questions or need any clarification as you complete this application, don't hesitate to reach out to us at lammha@ccalac.org.

First Name

* must provide value

Last Name

* must provide value

Email Address

* must provide value

Confirm Email Address

* must provide value

Title

* must provide value

What is the name of your health center?

* must provide value

What is the zip code of your corporate location?

* must provide value

Provide the first and last name of your primary point of contact for the project.

* must provide value

Email address of the above primary point of contact?

* must provide value

Please identify 3-4 team member roles that you anticipate will participate in the project from your health center (check all that apply).

* must provide value

Executive Leadership

Primary Care Provider (PCP)

Pediatric Provider

Obstetrician

Nurse or Nurse Practitioner

Midwife

Administrative Staff

Psychiatric Consultant

Behavioral Health Provider (LCSW, LMFT, etc.)

QI Staff

Other

Please specify "Other."

Identify the population of focus for the project (check all that apply).

* must provide value

Prenatal patients

Postpartum patients

Pediatric patients

Other

Please specify "Other."

The project will use continuous quality improvement to direct practice change. Please select your QI areas of focus within your perinatal populations (we can help you refine as part of your work with the project).

* must provide value

Screening for depression/suicide risk

Treatment/clinical intervention options for depression/suicide risk

Care coordination/continuity of care

Other

Please define "Other."

Please indicate the number of sites you are applying for.

* must provide value

1 site

2 sites

3 sites

4 sites

5 or more sites

LAMMHA Implementation Site Application Form

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