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Training/TA Request
If you have a general question or need information, use the
Request Information
form.
Your Name (first & last)
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Your Email Address
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Your Email Address (again)
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Phone Number
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Role at Organization
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Organization Type
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Hospital
Community Health Center
Behavioral Health Organization
Other Health Clinic
School-based Setting
Professional Organization
Higher Ed Institution
Other
Organization/Agency
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Department and/or Program
Populations Served
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Adolescents
Adults
Older Adults
Priority Populations- check if you predominantly serve any of the following populations:
Women
Pregnant Women
Veterans
Individuals with Chronic Medical Conditions
Individuals with Chronic Behavioral Health Conditions
LGBTQIA+
Racial/Ethnic Minorities
Non-English Speakers
Individuals with Housing Instability
Individuals who are Incarcerated/Previously Incarcerated
Other
What services does your organization offer?
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Does your organization currently screen for unhealthy substance use?
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Yes
No
Unsure
What type of assistance are you requesting?
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Training
Technical Assistance
Information
Audience for training/TA
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Clinical Staff (e.g., MD, RN, SW, LMHC)
Leadership Staff
Students/Interns
Support Staff
Other
Describe the needs of your organization that you would like addressed by MASBIRT TTA.
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