Diabetes Awareness Month, Funding Status Update, and More! 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Health Center Name, Street Address, City, State, and Zip Code in the designated fields.
3. Fill out the required sections for Prescribing Provider and Behavioral Health Provider. Ensure you include their names, job titles, credentials, work phone numbers, and emails.
4. If applicable, add details for any Other Staff Member in the optional section provided.
5. Answer the eligibility questions regarding your health center's status as a community health center or FQHC and provide information on adolescent patient visits.
6. Complete the open-ended questions about your health center’s priority adolescent health issues and expectations from participating in the program.
7. Ensure all applicants sign where indicated and that supervisors acknowledge their support for participation.

Start filling out your form today for free using our platform to streamline your application process!