D'Youville SUDS Program Application

Please complete the form below to apply for admission to the SUDS Program.

Demographic information is solely for the purpose of grant reporting.
This eight-week program includes live sessions delivered using Zoom. In addition, students will participate in live, in-person simulations and attend five 8-hour day sessions shadowing at a treatment site determined in consultation with the Clinical Coordinator, Dr. Todd Walter. To participate in this program, students must be 18 years or older, have a GED or High School diploma, have up-to-date immunizations, and pass a background check demonstrating eligibility to work in a healthcare facility. Program participation requires a computer with internet access. Students must be able to attend all sessions.
Name

First NameMiddle InitialLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
YesNo
April 3 - May 26 2023June 26 - August 18 2023
YesNo
YesNoMaybe
YesNoMaybe
YesNoMaybe
Employed full-time in the substance-use treatment fieldEmployed part-time in the substance-use treatment fieldEmployed full-time in another mental health fieldEmployed part-time in another mental health fieldEmployed full-time in a different fieldEmployed part-time in a different fieldNot currently employed
YesNo
Date of Birth

MonthDayYear
Date
FemaleMale
YesNo
American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or other Pacific IslanderWhiteOther
YesNo
YesNo
Active duty militaryNational GuardReservistVeteran - prior serviceVeteran - retiredNot a member or veteran of the US military
Why are you interested in this program and what benefits will you gain as a participant in this program?
What is your experience with recovery from substance use disorder and or working with individuals in recovery from substance use disorder? If you do not have any experience, please describe why you would like to work with individuals in recovery.
Is there anything else we should know that would assist you in being successful in this program?
How did you learn about this program?
Should be Empty:

Please complete the form below to apply for admission to the SUDS Program.