PEER Center</title>
  <meta http-equiv="Content-Type" content="text/html; charset=utf-8"/>
<!--[if IE]>
    <script type="text/javascript" src="/peer_center/misc/jquery.js"></script>
    <script type="text/javascript" src="/peer_center/misc/drupal.js"></script>
    <script type="text/javascript" src="/peer_center/sites/all/modules/nice_menus/nice_menus.js"></script>
    <![endif]-->
<link rel="shortcut icon" href="https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/favicon.ico" type="image/x-icon"/>
  <style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/modules/node/node.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/modules/system/defaults.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/modules/system/system.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/modules/user/user.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/calendar/calendar.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/cck/content.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/date/date.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/event/event.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/extlink/extlink.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/nice_menus/nice_menus.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/nice_menus/nice_menus_default.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/modules/logintoboggan/logintoboggan.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/cck/fieldgroup.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/panels/css/panels.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/all/modules/devel/devel.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/themes/custom/peer_center/style.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/themes/custom/peer_center/layout.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/themes/custom/peer_center/icons.css";</style>
<style type="text/css" media="all">@import "https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/themes/custom/peer_center/peer_center.css";</style>
<style type="text/css" media="print">@import "https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/themes/custom/peer_center/print.css";</style>
  <script type="text/javascript" src="https://www.hdwg.org/files/peer_center/misc/jquery.js"></script>
<script type="text/javascript" src="https://www.hdwg.org/files/peer_center/misc/drupal.js"></script>
<script type="text/javascript" src="https://www.hdwg.org/files/peer_center/sites/all/modules/extlink/extlink.js"></script>
<script type="text/javascript" src="https://www.hdwg.org/files/peer_center/sites/all/modules/panels/js/panels.js"></script>
<script type="text/javascript" src="https://www.hdwg.org/files/peer_center/sites/all/modules/devel/devel.js"></script>
<script type="text/javascript" src="https://www.hdwg.org/files/peer_center/sites/all/modules/custom/accordian/accordian.js"></script>
<script type="text/javascript">Drupal.extend({ settings: { "extlink": { "extTarget": 0, "extClass": "ext", "extSubdomains": 1, "mailtoClass": "mailto" }, "googleanalytics": { "trackDownload": "pdf|zip|mp3" } } });</script>
    <style>
        #wpadminbar #wp-admin-bar-p404_free_top_button .ab-icon:before {
            content: "\f103";
            color:red;
            top: 2px;
        }
    </style>
    <meta name='robots' content='index, follow, max-image-preview:large, max-snippet:-1, max-video-preview:-1' />

	<!-- This site is optimized with the Yoast SEO plugin v22.2 - https://yoast.com/wordpress/plugins/seo/ -->
	<link rel="canonical" href="https://www.hdwg.org/peer_center/referral" />
	<meta property="og:type" content="article" />
	<meta property="og:title" content="Organizational Capacity Building Referral Form | PEER Center" />
	<meta property="og:description" content="Home :: Organizational Capacity Building Referral Form Organizational Capacity [&hellip;]" />
	<meta property="og:url" content="https://www.hdwg.org/peer_center/referral" />
	<meta property="og:site_name" content="The Health &amp; Disability Working Group (HDWG) | Health &amp; Disability Working Group" />
	<meta name="twitter:card" content="summary_large_image" />
	<!-- / Yoast SEO plugin. -->


<script type="text/javascript">
/* <![CDATA[ */
window._wpemojiSettings = {"baseUrl":"https:\/\/s.w.org\/images\/core\/emoji\/15.0.3\/72x72\/","ext":".png","svgUrl":"https:\/\/s.w.org\/images\/core\/emoji\/15.0.3\/svg\/","svgExt":".svg","source":{"concatemoji":"https:\/\/www.hdwg.org\/wp-includes\/js\/wp-emoji-release.min.js?ver=6.6.2"}};
/*! This file is auto-generated */
!function(i,n){var o,s,e;function c(e){try{var t={supportTests:e,timestamp:(new Date).valueOf()};sessionStorage.setItem(o,JSON.stringify(t))}catch(e){}}function p(e,t,n){e.clearRect(0,0,e.canvas.width,e.canvas.height),e.fillText(t,0,0);var t=new Uint32Array(e.getImageData(0,0,e.canvas.width,e.canvas.height).data),r=(e.clearRect(0,0,e.canvas.width,e.canvas.height),e.fillText(n,0,0),new Uint32Array(e.getImageData(0,0,e.canvas.width,e.canvas.height).data));return t.every(function(e,t){return e===r[t]})}function u(e,t,n){switch(t){case"flag":return n(e,"\ud83c\udff3\ufe0f\u200d\u26a7\ufe0f","\ud83c\udff3\ufe0f\u200b\u26a7\ufe0f")?!1:!n(e,"\ud83c\uddfa\ud83c\uddf3","\ud83c\uddfa\u200b\ud83c\uddf3")&&!n(e,"\ud83c\udff4\udb40\udc67\udb40\udc62\udb40\udc65\udb40\udc6e\udb40\udc67\udb40\udc7f","\ud83c\udff4\u200b\udb40\udc67\u200b\udb40\udc62\u200b\udb40\udc65\u200b\udb40\udc6e\u200b\udb40\udc67\u200b\udb40\udc7f");case"emoji":return!n(e,"\ud83d\udc26\u200d\u2b1b","\ud83d\udc26\u200b\u2b1b")}return!1}function f(e,t,n){var r="undefined"!=typeof WorkerGlobalScope&&self instanceof WorkerGlobalScope?new OffscreenCanvas(300,150):i.createElement("canvas"),a=r.getContext("2d",{willReadFrequently:!0}),o=(a.textBaseline="top",a.font="600 32px Arial",{});return e.forEach(function(e){o[e]=t(a,e,n)}),o}function t(e){var t=i.createElement("script");t.src=e,t.defer=!0,i.head.appendChild(t)}"undefined"!=typeof Promise&&(o="wpEmojiSettingsSupports",s=["flag","emoji"],n.supports={everything:!0,everythingExceptFlag:!0},e=new Promise(function(e){i.addEventListener("DOMContentLoaded",e,{once:!0})}),new Promise(function(t){var n=function(){try{var e=JSON.parse(sessionStorage.getItem(o));if("object"==typeof e&&"number"==typeof e.timestamp&&(new Date).valueOf()<e.timestamp+604800&&"object"==typeof e.supportTests)return e.supportTests}catch(e){}return null}();if(!n){if("undefined"!=typeof Worker&&"undefined"!=typeof OffscreenCanvas&&"undefined"!=typeof URL&&URL.createObjectURL&&"undefined"!=typeof Blob)try{var e="postMessage("+f.toString()+"("+[JSON.stringify(s),u.toString(),p.toString()].join(",")+"));",r=new Blob([e],{type:"text/javascript"}),a=new Worker(URL.createObjectURL(r),{name:"wpTestEmojiSupports"});return void(a.onmessage=function(e){c(n=e.data),a.terminate(),t(n)})}catch(e){}c(n=f(s,u,p))}t(n)}).then(function(e){for(var t in e)n.supports[t]=e[t],n.supports.everything=n.supports.everything&&n.supports[t],"flag"!==t&&(n.supports.everythingExceptFlag=n.supports.everythingExceptFlag&&n.supports[t]);n.supports.everythingExceptFlag=n.supports.everythingExceptFlag&&!n.supports.flag,n.DOMReady=!1,n.readyCallback=function(){n.DOMReady=!0}}).then(function(){return e}).then(function(){var e;n.supports.everything||(n.readyCallback(),(e=n.source||{}).concatemoji?t(e.concatemoji):e.wpemoji&&e.twemoji&&(t(e.twemoji),t(e.wpemoji)))}))}((window,document),window._wpemojiSettings);
/* ]]> */
</script>
<style id='wp-emoji-styles-inline-css' type='text/css'>

	img.wp-smiley, img.emoji {
		display: inline !important;
		border: none !important;
		box-shadow: none !important;
		height: 1em !important;
		width: 1em !important;
		margin: 0 0.07em !important;
		vertical-align: -0.1em !important;
		background: none !important;
		padding: 0 !important;
	}
</style>
<link rel='stylesheet' id='wp-block-library-css' href='https://www.hdwg.org/wp-includes/css/dist/block-library/style.min.css?ver=6.6.2' type='text/css' media='all' />
<style id='classic-theme-styles-inline-css' type='text/css'>
/*! This file is auto-generated */
.wp-block-button__link{color:#fff;background-color:#32373c;border-radius:9999px;box-shadow:none;text-decoration:none;padding:calc(.667em + 2px) calc(1.333em + 2px);font-size:1.125em}.wp-block-file__button{background:#32373c;color:#fff;text-decoration:none}
</style>
<style id='global-styles-inline-css' type='text/css'>
:root{--wp--preset--aspect-ratio--square: 1;--wp--preset--aspect-ratio--4-3: 4/3;--wp--preset--aspect-ratio--3-4: 3/4;--wp--preset--aspect-ratio--3-2: 3/2;--wp--preset--aspect-ratio--2-3: 2/3;--wp--preset--aspect-ratio--16-9: 16/9;--wp--preset--aspect-ratio--9-16: 9/16;--wp--preset--color--black: #000000;--wp--preset--color--cyan-bluish-gray: #abb8c3;--wp--preset--color--white: #ffffff;--wp--preset--color--pale-pink: #f78da7;--wp--preset--color--vivid-red: #cf2e2e;--wp--preset--color--luminous-vivid-orange: #ff6900;--wp--preset--color--luminous-vivid-amber: #fcb900;--wp--preset--color--light-green-cyan: #7bdcb5;--wp--preset--color--vivid-green-cyan: #00d084;--wp--preset--color--pale-cyan-blue: #8ed1fc;--wp--preset--color--vivid-cyan-blue: #0693e3;--wp--preset--color--vivid-purple: #9b51e0;--wp--preset--gradient--vivid-cyan-blue-to-vivid-purple: linear-gradient(135deg,rgba(6,147,227,1) 0%,rgb(155,81,224) 100%);--wp--preset--gradient--light-green-cyan-to-vivid-green-cyan: linear-gradient(135deg,rgb(122,220,180) 0%,rgb(0,208,130) 100%);--wp--preset--gradient--luminous-vivid-amber-to-luminous-vivid-orange: linear-gradient(135deg,rgba(252,185,0,1) 0%,rgba(255,105,0,1) 100%);--wp--preset--gradient--luminous-vivid-orange-to-vivid-red: linear-gradient(135deg,rgba(255,105,0,1) 0%,rgb(207,46,46) 100%);--wp--preset--gradient--very-light-gray-to-cyan-bluish-gray: linear-gradient(135deg,rgb(238,238,238) 0%,rgb(169,184,195) 100%);--wp--preset--gradient--cool-to-warm-spectrum: linear-gradient(135deg,rgb(74,234,220) 0%,rgb(151,120,209) 20%,rgb(207,42,186) 40%,rgb(238,44,130) 60%,rgb(251,105,98) 80%,rgb(254,248,76) 100%);--wp--preset--gradient--blush-light-purple: linear-gradient(135deg,rgb(255,206,236) 0%,rgb(152,150,240) 100%);--wp--preset--gradient--blush-bordeaux: linear-gradient(135deg,rgb(254,205,165) 0%,rgb(254,45,45) 50%,rgb(107,0,62) 100%);--wp--preset--gradient--luminous-dusk: linear-gradient(135deg,rgb(255,203,112) 0%,rgb(199,81,192) 50%,rgb(65,88,208) 100%);--wp--preset--gradient--pale-ocean: linear-gradient(135deg,rgb(255,245,203) 0%,rgb(182,227,212) 50%,rgb(51,167,181) 100%);--wp--preset--gradient--electric-grass: linear-gradient(135deg,rgb(202,248,128) 0%,rgb(113,206,126) 100%);--wp--preset--gradient--midnight: linear-gradient(135deg,rgb(2,3,129) 0%,rgb(40,116,252) 100%);--wp--preset--font-size--small: 13px;--wp--preset--font-size--medium: 20px;--wp--preset--font-size--large: 36px;--wp--preset--font-size--x-large: 42px;--wp--preset--spacing--20: 0.44rem;--wp--preset--spacing--30: 0.67rem;--wp--preset--spacing--40: 1rem;--wp--preset--spacing--50: 1.5rem;--wp--preset--spacing--60: 2.25rem;--wp--preset--spacing--70: 3.38rem;--wp--preset--spacing--80: 5.06rem;--wp--preset--shadow--natural: 6px 6px 9px rgba(0, 0, 0, 0.2);--wp--preset--shadow--deep: 12px 12px 50px rgba(0, 0, 0, 0.4);--wp--preset--shadow--sharp: 6px 6px 0px rgba(0, 0, 0, 0.2);--wp--preset--shadow--outlined: 6px 6px 0px -3px rgba(255, 255, 255, 1), 6px 6px rgba(0, 0, 0, 1);--wp--preset--shadow--crisp: 6px 6px 0px rgba(0, 0, 0, 1);}:where(.is-layout-flex){gap: 0.5em;}:where(.is-layout-grid){gap: 0.5em;}body .is-layout-flex{display: flex;}.is-layout-flex{flex-wrap: wrap;align-items: center;}.is-layout-flex > :is(*, div){margin: 0;}body .is-layout-grid{display: grid;}.is-layout-grid > :is(*, div){margin: 0;}:where(.wp-block-columns.is-layout-flex){gap: 2em;}:where(.wp-block-columns.is-layout-grid){gap: 2em;}:where(.wp-block-post-template.is-layout-flex){gap: 1.25em;}:where(.wp-block-post-template.is-layout-grid){gap: 1.25em;}.has-black-color{color: var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-color{color: var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-color{color: var(--wp--preset--color--white) !important;}.has-pale-pink-color{color: var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-color{color: var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-color{color: var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-color{color: var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-color{color: var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-color{color: var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-color{color: var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-color{color: var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-color{color: var(--wp--preset--color--vivid-purple) !important;}.has-black-background-color{background-color: var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-background-color{background-color: var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-background-color{background-color: var(--wp--preset--color--white) !important;}.has-pale-pink-background-color{background-color: var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-background-color{background-color: var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-background-color{background-color: var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-background-color{background-color: var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-background-color{background-color: var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-background-color{background-color: var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-background-color{background-color: var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-background-color{background-color: var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-background-color{background-color: var(--wp--preset--color--vivid-purple) !important;}.has-black-border-color{border-color: var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-border-color{border-color: var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-border-color{border-color: var(--wp--preset--color--white) !important;}.has-pale-pink-border-color{border-color: var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-border-color{border-color: var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-border-color{border-color: var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-border-color{border-color: var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-border-color{border-color: var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-border-color{border-color: var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-border-color{border-color: var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-border-color{border-color: var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-border-color{border-color: var(--wp--preset--color--vivid-purple) !important;}.has-vivid-cyan-blue-to-vivid-purple-gradient-background{background: var(--wp--preset--gradient--vivid-cyan-blue-to-vivid-purple) !important;}.has-light-green-cyan-to-vivid-green-cyan-gradient-background{background: var(--wp--preset--gradient--light-green-cyan-to-vivid-green-cyan) !important;}.has-luminous-vivid-amber-to-luminous-vivid-orange-gradient-background{background: var(--wp--preset--gradient--luminous-vivid-amber-to-luminous-vivid-orange) !important;}.has-luminous-vivid-orange-to-vivid-red-gradient-background{background: var(--wp--preset--gradient--luminous-vivid-orange-to-vivid-red) !important;}.has-very-light-gray-to-cyan-bluish-gray-gradient-background{background: var(--wp--preset--gradient--very-light-gray-to-cyan-bluish-gray) !important;}.has-cool-to-warm-spectrum-gradient-background{background: var(--wp--preset--gradient--cool-to-warm-spectrum) !important;}.has-blush-light-purple-gradient-background{background: var(--wp--preset--gradient--blush-light-purple) !important;}.has-blush-bordeaux-gradient-background{background: var(--wp--preset--gradient--blush-bordeaux) !important;}.has-luminous-dusk-gradient-background{background: var(--wp--preset--gradient--luminous-dusk) !important;}.has-pale-ocean-gradient-background{background: var(--wp--preset--gradient--pale-ocean) !important;}.has-electric-grass-gradient-background{background: var(--wp--preset--gradient--electric-grass) !important;}.has-midnight-gradient-background{background: var(--wp--preset--gradient--midnight) !important;}.has-small-font-size{font-size: var(--wp--preset--font-size--small) !important;}.has-medium-font-size{font-size: var(--wp--preset--font-size--medium) !important;}.has-large-font-size{font-size: var(--wp--preset--font-size--large) !important;}.has-x-large-font-size{font-size: var(--wp--preset--font-size--x-large) !important;}
:where(.wp-block-post-template.is-layout-flex){gap: 1.25em;}:where(.wp-block-post-template.is-layout-grid){gap: 1.25em;}
:where(.wp-block-columns.is-layout-flex){gap: 2em;}:where(.wp-block-columns.is-layout-grid){gap: 2em;}
:root :where(.wp-block-pullquote){font-size: 1.5em;line-height: 1.6;}
</style>
<link rel="https://api.w.org/" href="https://www.hdwg.org/wp-json/" /><link rel="alternate" title="JSON" type="application/json" href="https://www.hdwg.org/wp-json/wp/v2/pages/1056" /><link rel="EditURI" type="application/rsd+xml" title="RSD" href="https://www.hdwg.org/xmlrpc.php?rsd" />
<meta name="generator" content="WordPress 6.6.2" />
<link rel='shortlink' href='https://www.hdwg.org/?p=1056' />
<link rel="alternate" title="oEmbed (JSON)" type="application/json+oembed" href="https://www.hdwg.org/wp-json/oembed/1.0/embed?url=https%3A%2F%2Fwww.hdwg.org%2Fpeer_center%2Freferral" />
<link rel="alternate" title="oEmbed (XML)" type="text/xml+oembed" href="https://www.hdwg.org/wp-json/oembed/1.0/embed?url=https%3A%2F%2Fwww.hdwg.org%2Fpeer_center%2Freferral&#038;format=xml" />
<meta name="viewport" content="width=device-width, initial-scale=1">

<!-- Google tag (gtag.js) -->
<script async src="https://www.googletagmanager.com/gtag/js?id=G-9QHMWHWG71"></script>
<script>
  window.dataLayer = window.dataLayer || [];
  function gtag(){dataLayer.push(arguments);}
  gtag('js', new Date());

  gtag('config', 'G-9QHMWHWG71');
</script></head>
<body class="not-front not-logged-in ntype-page sidebar-left">
  <div id="page">
    <div id="account">
      <a href="https://www.hdwg.org/peer_center/user/login">Login</a> | <a href="https://www.hdwg.org/peer_center/user/register">Register</a>    </div><!-- /account -->
    <div id="header">
      <div id="skip-nav"><a href="#content">Skip to Main Content</a></div>
      <div id="logo-title">
        <div id="banner">
          <img src="https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/themes/custom/peer_center/images/banner.png" alt="A national resource and evaluation center for people living with HIV and organizations interested in PEER education training programs"/>
        </div>
                  <div id="logo">
            <a href="https://www.hdwg.org/peer_center" title="Home" rel="home">
              <img src="https://www.hdwg.org/files/peer_center/sites/hdwg.org.peer_center/themes/custom/peer_center/images/peer_center_logo.png" alt="PEER Center"/>
            </a>
          </div>
      </div> <!-- /logo-title -->
    </div> <!-- /header -->
    <div id="container" class="clear-block">
              <div id="sidebar-left" class="column sidebar">
          <div id="block-nice_menus-1" class="block block-nice_menus">
  <div class="blockinner">
        <div class="content">
      <ul class="nice-menu nice-menu-right" id="nice-menu-1"><li id="menu-65" class="menu-path-front"><a href="https://www.hdwg.org/peer_center">Home</a></li>
<li id="menu-184" class="menu-path-news"><a href="https://www.hdwg.org/peer_center/news">News</a></li>
<li id="menu-74" class="menuparent menu-path-node-7"><a href="https://www.hdwg.org/peer_center/pet_sites">PET Sites</a><ul><li id="menu-75" class="menu-path-node-2"><a href="https://www.hdwg.org/peer_center/pet_sites/lotus">The Lotus Project</a></li>
<li id="menu-76" class="menu-path-node-3"><a href="https://www.hdwg.org/peer_center/pet_sites/pact">PACT Project</a></li>
<li id="menu-77" class="menu-path-node-4"><a href="https://www.hdwg.org/peer_center/pet_sites/peopletopeople">People to People</a></li>
</ul>
</li>
<li id="menu-148" class="menu-path-www.hdwg.org-peer_center-node-180"><a href="https://www.hdwg.org/peer_center/node/180">Newsletter</a></li>
<li id="menu-78" class="menu-path-events"><a href="https://www.hdwg.org/peer_center/events">Upcoming Events</a></li>
<li id="menu-142" class="menu-path-grantees"><a href="https://www.hdwg.org/peer_center/grantees">Grantees Only</a></li>
<li id="menu-122" class="menu-path-node-16"><a href="https://www.hdwg.org/peer_center/referral" class="active">Request Information</a></li>
<li id="menu-73" class="menu-path-resources"><a href="https://www.hdwg.org/peer_center/resources">Peer Program Resources</a></li>
<li id="menu-72" class="menu-path-contact"><a href="https://www.hdwg.org/peer_center/contact">Contact Us</a></li>
</ul>
    </div>
  </div>
</div>
<div id="block-block-1" class="block block-block">
  <div class="blockinner">
        <div class="content">
      <div class="projects"><a href="https://www.hdwg.org"><img src="https://www.hdwg.org/files/peer_center/sites/all/sidebar/hdwg_logo_small.gif" alt="Health and Disability Working Group"/></a></div><div class="projects"><a href="http://sph.bu.edu/"><img src="https://www.hdwg.org/files/peer_center/sites/all/sidebar/busph_logo_small.gif" alt="Boston University School of Public Health"/></a></div><div class="projects"><a href="http://careacttarget.org/"><img src="https://www.hdwg.org/files/peer_center/sites/all/sidebar/target_center_logo_small.gif" alt="Target Center"/></a></div>    </div>
  </div>
</div>
        </div> <!-- /sidebar-left -->		<link rel="stylesheet" type="text/css" media="all" href="https://www.hdwg.org/wp-content/themes/qxf02yz8ywf9vv3jgbdwd233292/style.css" />
	<div id="main" class="column"><div id="squeeze" class="clear-block">
    <div id="breadcrumbs">
      <div class="breadcrumb"><a href="https://www.hdwg.org/peer_center">Home</a> :: Organizational Capacity Building Referral Form</div>    </div> <!-- /breadcrumbs -->
        <div id="content">
                      <h1 class="title">Organizational Capacity Building Referral Form</h1>
                                                  <div class="node ntype-webform" id="node-16">
  <div class="content">
    Interested in implementing or expanding a peer program within your organization?  Please complete the form below so we can tailor our information to better meet your needs.<form action="https://www.hdwg.org/peer_center/referral" accept-charset="UTF-8" method="post" id="webform-client-form-16" enctype="multipart/form-data">
<div><input type="hidden" name="submitted[hidden_subject]" id="edit-submitted-hidden-subject" value="PEER Center - Request Information submission"/>
<fieldset class="webform-component-fieldset" id="webform-component-contact_info"><legend>I. Contact Information</legend><div class="webform-component-textfield" id="webform-component-agency_name"><div class="form-item">
 <label for="edit-submitted-contact-info-agency-name">Agency/Program Name: </label>
 <input type="text" maxlength="128" name="submitted[contact_info][agency_name]" id="edit-submitted-contact-info-agency-name" size="60" value="" class="form-text"/>
</div>
</div><div class="webform-component-textfield" id="webform-component-contact_name"><div class="form-item">
 <label for="edit-submitted-contact-info-contact-name">Contact Name: <span class="form-required" title="This field is required.">*</span></label>
 <input type="text" maxlength="128" name="submitted[contact_info][contact_name]" id="edit-submitted-contact-info-contact-name" size="60" value="" class="form-text required"/>
</div>
</div><div class="webform-component-textfield" id="webform-component-title"><div class="form-item">
 <label for="edit-submitted-contact-info-title">Title: </label>
 <input type="text" maxlength="128" name="submitted[contact_info][title]" id="edit-submitted-contact-info-title" size="60" value="" class="form-text"/>
</div>
</div><div class="webform-component-textfield" id="webform-component-address"><div class="form-item">
 <label for="edit-submitted-contact-info-address">Agency Address: </label>
 <input type="text" maxlength="128" name="submitted[contact_info][address]" id="edit-submitted-contact-info-address" size="60" value="" class="form-text"/>
</div>
</div><div class="webform-component-textfield" id="webform-component-city"><div class="form-item">
 <label for="edit-submitted-contact-info-city">City: <span class="form-required" title="This field is required.">*</span></label>
 <input type="text" maxlength="80" name="submitted[contact_info][city]" id="edit-submitted-contact-info-city" size="40" value="" class="form-text required"/>
</div>
</div><div class="webform-component-select" id="webform-component-state"><div class="form-item">
 <label for="edit-submitted-contact-info-state">State: <span class="form-required" title="This field is required.">*</span></label>
 <select name="submitted[contact_info][state]" class="form-select required" id="edit-submitted-contact-info-state"><option value="" selected="selected">select&#8230;</option><option value="al">AL</option><option value="ak">AK</option><option value="az">AZ</option><option value="ar">AR</option><option value="ca">CA</option><option value="co">CO</option><option value="ct">CT</option><option value="de">DE</option><option value="dc">DC</option><option value="fl">FL</option><option value="ga">GA</option><option value="gu">GU</option><option value="hi">HI</option><option value="id">ID</option><option value="il">IL</option><option value="in">IN</option><option value="ia">IA</option><option value="ks">KS</option><option value="ky">KY</option><option value="la">LA</option><option value="me">ME</option><option value="md">MD</option><option value="ma">MA</option><option value="mi">MI</option><option value="mn">MN</option><option value="ms">MS</option><option value="mo">MO</option><option value="mt">MT</option><option value="ne">NE</option><option value="nv">NV</option><option value="nh">NH</option><option value="nj">NJ</option><option value="nm">NM</option><option value="ny">NY</option><option value="nc">NC</option><option value="nd">ND</option><option value="oh">OH</option><option value="ok">OK</option><option value="or">OR</option><option value="pa">PA</option><option value="pr">PR</option><option value="ri">RI</option><option value="sc">SC</option><option value="sd">SD</option><option value="tn">TN</option><option value="tx">TX</option><option value="ut">UT</option><option value="vt">VT</option><option value="va">VA</option><option value="vi">VI</option><option value="wa">WA</option><option value="wv">WV</option><option value="wi">WI</option><option value="wy">WY</option></select>
</div>
</div><div class="webform-component-textfield" id="webform-component-zip"><div class="form-item">
 <label for="edit-submitted-contact-info-zip">Zip: <span class="form-required" title="This field is required.">*</span></label>
 <input type="text" maxlength="10" name="submitted[contact_info][zip]" id="edit-submitted-contact-info-zip" size="10" value="" class="form-text required"/>
</div>
</div><div class="webform-component-textfield" id="webform-component-phone"><div class="form-item">
 <label for="edit-submitted-contact-info-phone">Phone: </label>
 <input type="text" maxlength="20" name="submitted[contact_info][phone]" id="edit-submitted-contact-info-phone" size="20" value="" class="form-text"/>
</div>
</div><div class="webform-component-email" id="webform-component-email"><div class="form-item">
 <label for="edit-submitted-contact-info-email">E-mail: </label>
 <input type="text" maxlength="128" name="submitted[contact_info][email]" id="edit-submitted-contact-info-email" size="20" value="" class="form-text"/>
</div>
</div><div class="webform-component-textfield" id="webform-component-fax"><div class="form-item">
 <label for="edit-submitted-contact-info-fax">Fax: </label>
 <input type="text" maxlength="20" name="submitted[contact_info][fax]" id="edit-submitted-contact-info-fax" size="20" value="" class="form-text"/>
</div>
</div><div class="webform-component-textarea" id="webform-component-learn"><div class="form-item">
 <label for="edit-submitted-contact-info-learn">How did you learn about this technical assistance?: </label>
 <textarea rows="3" name="submitted[contact_info][learn]" id="edit-submitted-contact-info-learn" class="form-textarea resizable"></textarea>
</div>
</div></fieldset>
<input type="hidden" name="details[page_num]" id="edit-details-page-num" value="1"/>
<input type="hidden" name="details[email_subject]" id="edit-details-email-subject" value="hidden_subject"/>
<input type="hidden" name="details[email_from_name]" id="edit-details-email-from-name" value="default"/>
<input type="hidden" name="details[email_from_address]" id="edit-details-email-from-address" value="E-mail"/>
<input type="hidden" name="form_build_id" id="73ef229bec1eacb4b823863a518f063c" value="73ef229bec1eacb4b823863a518f063c"/>
<input type="hidden" name="form_id" id="edit-webform-client-form-16" value="webform_client_form_16"/>
<input type="submit" name="op" id="edit-submitbutton-next" value="Next Page >&#8221; class=&#8221;form-submit&#8221;/>
</div></form>
  </div>
</div>
                  </div> <!-- /content -->
              </div></div> <!-- /squeeze /main -->
    </div> <!-- /container -->
    <div id="footer-wrapper"><div id="footer">
        <strong>PEER Center • Health & Disability Working Group • BU School of Public Health • 374 Congress Street • Suite 502 • Boston, MA 02210 • (617) 426-4447<br/>
© 2009 Health & Disability Working Group</strong>
      </div> <!-- /footer -->
    </div> <!-- /footer-wrapper -->
 
   </div> <!-- /page -->
</body>
</html>