Application for Training, Consultation or Technical Assistance Services

Please fill in the form below to make a request for training, consultation or technical assistance services.

Applicant Information  
Contact First Name: Contact Last Name:
Title: Phone:
E-mail: FAX:
       
Organization: Address:


     
City: Zip:
County: Website:

 

How did you hear about our services?  (Please check just one.)
     
Training Event/Brochure Previous Utilization of Services
County AOD Program Internet Search
Colleague Consultant
Dept of Alcohol and Drug Programs Newsletter
Other Please List:  

 

Would you please tell us a bit about your organization:

Organization Description    
Which of the categories below that best describes your organization?   (Please check just one.)
     
Business/Professional Association County AOD Program
Board Other County Agency
Coalition/Community Partnership Health Service Agency
Community-Based Organization Law Enforcement
Treatment Provider Neighborhood/Housing
City Agency Faith Based Organization
State Agency Education - K-12
Federal Agency Education - Post Secondary
Other Please List:  

 

What services does your agency provide?   (Please check all that apply.)
     
Start Up Residential Detoxification
Outpatient Counseling Residential Treatment (30 Days or Less)
Intensive Outpatient Residential Treatment (More than 30 Days)
Outpatient Detoxification Transitional Housing
NTP Sober Living
Other Medication-Assisted Treatment    
Other Please List:  

 

Do your planned or current AOD treatment services focus on any particular population group(s)?  (Please check all that apply.)
     
General Population Disabled
Men Offenders
Women Latino
Pregnant Women African American
Women with Children Asian-Pacific Islander
Youth Native American
LGBTQ Older Adult
Other Please List:  

 

 
How long has your agency been providing AOD treatment services? years
   
About how many clients were admitted to your AOD services last year?
   
What is your agency's total SUD services budget for this fiscal year?
   

How many counselors are on staff?

 FTE's

 

What are the primary funding source(s) supporting your organization in this fiscal year.   (Please check all that apply.)
     
County AOD Program Short-Doyle Medi-Cal
Drug Medi-Cal MHSA (Prop 63)
Criminal Justice System Private Insurance
Child Welfare System Other County Agency
State Grant(s) Federal Grant(s)
Other Please List:  

What is the nature of your request?

What is the opportunity or challenge you want assistance with?
   
What is the service you need?
   
What is the result you want?
   

 

 
Preferred Date(s) or Timeline for Service:
Estimated Number of Participants:
Preferred Location of Services:

 

Please print this page before clicking on the Submit button if you would like to keep a copy for your records.

 

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