Registration: Preparing your Health Center for SBIRT Implementation

Name*

First Last

Organization*

Position/Role*

Address*

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

Mobile Phone Number

As part of additional engagement with the series, weekly SMS messages will be sent out 3-4 times weekly based on session content. By inputting your mobile phone number, you consent to receive SMS messages. Message and data rates may apply. To opt-out of once the series begins, reply to a message with STOP.

Email Address*

By providing your email address, you will be added to the Mountain Plains ATTC mailing list; to opt-out, please contact mpattc@casat.org

Enter Email Confirm Email

Password*

Enter Password Confirm Password

Strength indicator

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

Note: The intended audience for this series are community health workers, medical assistants, nurses, and behavioral health providers currently using SBIRT or in the process of implementing SBIRT in a healthcare setting.

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 participating in the SBIRT-IP series?*

How did you learn about this event?

Are you Hispanic or Latino/a

Yes
No
Prefer not to answer

What is your race?

Specify*

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

Attend the one-hour orientation, commit to 6-weeks of training, complete weekly learning activities, and actively participate in discussions each week.

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