Health Education and Training Request Form

Health Education and Training Request Form
The Office of Problem Gambling provides health education services to aid in the identification of problem gambling behaviors and provide prevention and treatment resources to mitigate the effects problem gambling.

Health education services include outreach, consultation and training for health care professionals, educators, and nonprofit/community organizations. All health education services are provided at no cost and can be customized to meet the needs of the requestors, included providing continuing education units for the below listed licensing agencies, at no cost.
Date*

MonthDayYear
Date
Agency Name:*
Description (area of agency focus):*
Primary Contact person:*
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of service being requested:*

Consultation: Provided through scheduled virtual or on-site meetings at the requestor’s agency/facility, telephone conference or written correspondence.Outreach: Provided through scheduled on-site meetings at the requestor’s agency/facility, telephone conference, written correspondence, making presentations, establishing information booths at (not limited to) health fairs, associations and conference.Training: Provided through scheduled on-site meetings at the requestor’s agency/facility, video/web conference and Individual training event should be provided for the duration indicated in the approved curriculum presentations.
Has your agency received services from the Office of Problem Gambling (OPG) in the past?*

YesNo
If yes, please provide the date and details of services received. *
Should be Empty: