Unity Recovery - Training and Technical Assistance Request Form

Training and Technical Assistance Request Form
Please review and complete the following request form with as much information as possible to facilitate your request. Our T/TA team will be in touch within 48-hours of each request submitted to schedule a discovery call.
Name*

First NameLast Name
Pronouns used for communication*
Email*

Confirmation EmailPlease verify your email address
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred method of communication*
Organization Name*
Organization Website*
Role / Job Title of Requestor*
Primary Organization Type*

Recovery Community OrganizationClinical Treatment ProviderMedication Treatment ProviderHealth SystemThird Party PayorHospitalFQHCCMHCCBHCRecovery ResidenceTransitional Housing ProgramRe-entry ProgramSocial Service OrganizationLocal Government AgencyState Government AgencyProfessional Membership OrganizationJail / PrisonProbation / Parole DepartmentOther
Which best describes the community in which you work? Select all that apply*

FrontierRuralSuburbanUrbanTribal CommunitySmall TownLarge TownDigital Community (Websites, Social Media, Telephone, Video, etc)Virtual Community (Virtual Reality)Other
Who does your organization primarily serve (select all that apply)?*

Youth and Young AdultsAdultsOlder Adults (Geriatric Populations)People who use drugsPeople with mental health concernsPeople living unhousedPeople who identify as LGTBQIA+People who identify as BIPOCPregnant and Postpartum IndividualsFamily MembersThose who are currently or previously incarceratedPeople who identify as living in recoveryPrimarily male identifying individualsPrimarily female identifying individualsPrimarily trans identifying individualsPeople at high risk of overdose eventsOther
Please select the domain(s) that your request best fits into. Select other and type the topical area if it is not available in this list.*

General Recovery Support Service DeliveryDigital Recovery Support ServicesVirtual Recovery Support ServicesRecovery Planning / WRAP PlanningOverdose Prevention and ResponseXylazine (Tranq) Overview and Care DeliveryGeneral Harm Reduction ServicesWound Care ServicesDrug Checking ServicesSyringe Service ProgramsRecovery Friendly WorkplacesStigma and LanguageFamily Support ServicesRecovery Outcomes Data and AnalyticsRecoveryLink Use and Best PracticesRSS Cost AnalysisRSS IntegrationPeer SupervisionPeer Workforce DevelopmentCommunity Needs Assessment and MappingRe-entry or Forensic Peer ServicesPregnant and Postpartum Peer ServicesCommunity Outreach Best PracticesRecovery HousingRCO and Peer Service History and ModelsRCO Administration and LeadershipRecovery Science and ResearchOther
Preferred Event Delivery Channel*
How many expected attendees or impacted stakeholders would you estimate being a part of this event?*
Who is the intended audience for this request?*

Organizational StaffPartner Professional StaffCommunity MembersOther
Please describe your training and technical assistance needs as specifically and detailed as possible. A useful framework is to identify the barriers or obstacles you are facing (i.e., the problem you are attempting to overcome), the reason the opportunity exists and now is the time to address it, the type of activity you are hoping to use and why, and any other information that can help us understand your current needs.*
What do you hope will be different as a result of this training? What do you hope to achieve as an outcome following the delivery of this training in the near, mid, and long term?*
Ideal Event Delivery Date and Start Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
If your request is not covered under federal or state grant funding for the Unity T/TA recovery hub, do you have a budget for your request? Please describe.
Should be Empty: