Fee-for-Service Training and Technical Assistance Request Form

Thank you for your interest. Please include as much information as possible.
This will help us answer your questions. Required fields are indicated.

Name (required)

Agency (required)

Location (required)

Phone (required)

Email (required)

Type of Training or Technical Assistance (if the training is in our course catalog, please use that name) (required)

Range of Potential Dates (not required but preferred)

If you are requesting a training that is not one of our existing courses, what is the ideal length—in hours or days—of Training or Technical Assistance you want?

Approximate Number of Participants (required)

Background of Participants (check all that apply)
Licensed Mental Health ProvidersUnlicensed Mental Health ProvidersNursesDoctorsSubstance Use CounselorsNonclinical Front-Office StaffNonclinical Program Oversight Staff

Type of Agency and Reason for Training (required)