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Please send me _____ copies of the "Avoiding Medication Errors" DVD at $150 each. (Price includes shipping and handling.)  I have enclosed a check, payable to MHRRG, for $__________.

______________________________________
Name/Title

______________________________________
Organization

______________________________________
Address

______________________________________
City/State

______________________________________
Zip

Telephone (______) ______________________

Best time to call: [  ] a.m.     [  ] p.m.

Yes! I want to learn more about the Mental Health Risk Retention Group.

[  ]Send me more information. [   ]Have a representative contact me.

Is your organization a member of:

[  ] National Council for Community Behavioral Healthcare

[  ] Mental Health Corporations of America