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Specialized Policing Responses: Law Enforcement/Mental Health Learning Sites TECHNICAL ASSISTANCE REQUEST FORM The Law Enforcement/Mental Health Learning Sites project provides peer-to-peer support for groups interested in improving upon an existing—or planning a new—specialized policing response (SPR) to people with mental illnesses. Technical assistance from learning site representatives may include telephone and e-mail consultations, in addition to site visits to learn more from these agencies. To request technical assistance from a learning site, please complete this form and submit to Whitney Kujawa by e-mail ( or fax (240-497-0568). Your answers to these questions will help Justice Center staff identify the most appropriate learning site to respond to your inquiries. Contact Information—Please place an asterisk (*) next to your preferred method of contact. Name Title Address Telephone


E-mail Address Did your jurisdiction apply for a FY2009 or FY2010 BJA Justice and Mental Health Collaboration Program (JMHCP) grant? Yes No If so, did you receive a grant?



Please be as specific as possible. Our ability to refer you to an appropriate learning site and adequately respond to your request depends on the information you provide. Questions or Concerns—Please check the issue(s) or area(s) for which your jurisdiction would like assistance. (Check all that apply, and if you wish to elaborate, you may submit attachments.) Concerns about:

Interest in learning more about:

□ Injuries to officers and civilians as a result of encounters between law enforcement and people with mental illnesses

□ Specialized training

□ Time spent on calls for service involving a person with mental illness □ Repeat contact with high utilizers of emergency services □ Other (please explain)

□ Program design process □ Alternative dispositions (e.g., crisis receiving centers) □ Dispatcher protocols □ Special populations, such as juveniles or people experiencing homelessness □ Other (please explain)

Target Audience—Who is the target audience for the technical assistance? (Check all that apply.) □ Patrol officers □ Law enforcement leadership □ Mental health personnel □ Families and/or advocacy groups □ Consumers of mental health services □ Elected officials or other local leadership □ Other (please explain) Time Frame—Please list the time frame within which you would like to receive technical assistance. Please note any important, relevant upcoming dates for your jurisdiction or program.

Program Description—Provide a brief description of your planned or existing SPR. Please note how long it has been in the planning stages or in operation, actual or planned target population, and key agencies involved, etc.

Jurisdiction Description—Provide a brief description of your community context, including size; urban/rural/suburban; and special issues such as jail overcrowding, recent lawsuits, lack of services, etc.

Please check here if your jurisdiction is interested in applying for travel stipends from the Council of State Governments Justice Center. Please submit completed applications via e-mail, fax, or U.S. mail to: The Council of State Governments Justice Center | Attn.: Whitney Kujawa 4630 Montgomery Blvd. | Suite 650 | Bethesda, MD 20814 t. 240-482-8577 | f. 240-497-0568 | Page | 2 Technical Assistance Request Form