Registration: Preparing your Health Center for SBIRT Implementation

Name*

First Last

Mailing Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mobile Phone Number*

(Mountain Plains ATTC Staff & Consultants will be sending weekly SMS text messages related to course content. By inputting your mobile phone number, you consent to receive text messages sent through an automatic telephone dialing system.)

Email Address*

(by providing your email address, you will automatically be added to the Mountain Plains ATTC listserv; to opt-out, please contact mpattc@casat.org)

Enter Email Confirm Email

Password*

Enter Password Confirm Password

Strength indicator

Agency/Organization*

Credentials*

Current Position*

Physician
Physician Assistants
Nurse Practitioners
Nurse
Social Workers
Addiction Counselors
Peer Recovery Support Positions
Prevention

What do you consider yourself to be?*

Female
Male
Transgender (Male to Female)
Transgender (Female to Male)
Gender Non-Conforming
Prefer Not to Answer

Do you think of yourself as…*

Straight or Heterosexual
Homosexual (Gay or Lesbian)
Bisexual
Queer, Pansexual, and/or Questioning
Asexual
Prefer not to answer

Are you Hispanic or Latino/a*

Yes
No
Prefer not to answer

What is your race?*

Specify*

How did you learn about this event?*

Are you currently implementing SBIRT in your organization and/or practice?*

Yes
No

Do you have a background or have you attended SBIRT training?*

Yes
No

If yes, please explain.*

What do you hope to learn by taking the SBIRT-IP Workwise Series?*

By checking here you are indicating that you understand the technology requirements and participant commitment as follows:*

• Access to appropriate technology to utilize online videoconferencing platform (i.e., an internet connection, built-in or USB webcam, laptop/tablet, built-in/USB/Bluetooth speakers and microphone) • Attend a one-hour online Orientation Session on the scheduled date and time • Commit to 6-weeks of training for 1.5 hours weekly on scheduled series days/times. Participants are expected to be visible on camera 90% of the scheduled series time to earn the weekly 1.5 CE. • Complete one-hour of weekly self-study learning activities and participate in discussions during the weekly sessions verbally or via chat during the scheduled series days/times in order to receive the one-hour weekly learning activity CE.

I understand the time commitment involved and agree to fully participate.