Co-Occurring Disorders Registration - 8.2.1

Name*

First Last

Credentials*

Agency/Organization*

Current Position*

Physician
Physician Assistant
Nurse Practitioner
Nurse
Social Worker
Addiction Counselor
Peer Recovery Support Positions
Prevention
Other

Please describe*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

State where you work:*

Mobile Phone Number*

(Mountain Plains staff will send weekly SMS text messages related to course content. By inputting your phone number, you consent to receive text messages sent through an automatic telephone dialing system.)

Email*

(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

What is your sex?

Female
Male

Are you Hispanic or Latino/a?

Yes
No
Prefer not to answer

What is your race?

Specify

How did you learn about this event?*

Do you have a background in or have you attended a Co-Occurring Disorders training*

Yes
No

If yes, please explain.*

What do you hope to learn by taking the Co-Occurring Disorders Workwise Series?*

By checking here you are indicating that you understand the pre-requisite and technology requirements as well as the time commitment to participate in this training.*

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