Initial Interest Questionnaire

Fill out this form to get started!

We ask for your contact information as an aid to be able to assess and document the impact of our efforts. If you are not already a client of ECHO, we encourage to take the first step in qualifying for ECHO’s no-cost consulting services by completing this Initial Interest Questionnaire.

Name of Organization*
Name of Clinic
Address
Address Additional
City
State
Zip
Phone*
Email*
Website
What is the vision for your clinic? (i.e. population you want to serve, services you want to provide, outcomes you want to achieve, etc.)
Have you started the planning for your clinic? If yes, please describe your progress to date.
Have you assembled a planning group for your clinic? If so briefly describe its history, current composition, leadership, and meeting frequency.
How many doctors, nurses, and other health professionals belong to your church(es) and/or have expressed interest in volunteering for your clinic?
Have you identified a space for your clinic? If yes or maybe, please describe.
Are there other free or charitable clinics in your community? If so, please indicate if you have had any initial discussions with them.
How soon could your planning group meet with ECHO for a clinic planning workshop? within 30 Days within 60 Days within 90 Days more than 90 Days

All fields with an asterisk * are required.