ADAPT Request Form
Thank you for your interest in Family Connections ADAPT prevention programming and initiatives! ADAPT is a coalition of people who care about preventing and reducing substance use impacting Essex County communities, families, and individuals throughout their lifespan. These services are generously funded through grants from the Division of Mental Heath and Addiction Services and the Substance Abuse and Mental Health Services Administration. Please complete this form to make your request. Please note that we will need a minimum of two weeks notice prior to attending an event. Requests are subject to availability.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Please select if you are a youth, parent, or a community member representing one of the sectors listed.
*
Please Select
Youth (under 18 y/o)
Parent
Business
Media
School
Youth-Serving Organization
Law enforcement agencies
Religious or fraternal organizations
Healthcare professionals
State, local, or tribal agencies
Civic and volunteer groups
Other organizations
You may belong to more than one sector, but please select the one that best represents your role today as you complete this request.
If you are making this inquiry on behalf of an organization or business, please specify the name.
Name of org/business
Your Title
Resources
If you or someone you know is in need of a resource, please complete the following information.
Please select the type of resource you are requesting today.
Prevention Resources
Treatment Resources
Recovery Support/ Peer Services
Social Needs
Other
Please describe the resource(s) you need.
Substance Use Prevention Information
If requesting information about substances, please select which topic(s) you need.
Marijuana
Tobacco/Nicotine
Alcohol
Prescription Medications (including opioids)
Over-the-Counter Medications
Other
Metal Signs
We have metal No Smoking/ No Vaping/ No Marijuana Smoking signs available in English and in Spanish to post in public and indoor areas. Please specify the quantity needed for each language and the address where it will be posted.
How many "Breathe Easy" signs in English do you need?
How many "Breathe Easy" signs in Spanish do you need?
Address where the "Breathe Easy" signs will be posted
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Tabling Event
If you would like us to table at your upcoming event, please complete the following information.
Event Name
Event Date
-
Month
-
Day
Year
Date
Event Start Time
AM
PM
Event End Time
AM
PM
Event Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where does this event take place?
Indoors
Outdoors
Are table and chairs provided?
Yes
No
How many people do you anticipate attending this event?
What is the target audience of this event? (select all that apply)
Elementary school-aged youth
Middle school-aged youth
High school-aged youth
College-aged youth/young adults
Parents
Older Adults ages 60+
LGBTQ+
Professionals
General Public
Other
Please share any additional information about this event (e.g., parking information, etc.)
Speaking Engagement
To request a speaker for your event, please complete the following information.
Topic to Present
Type of speaker (select all that apply)
Individual speaker
Panel speaker
Other
How many people do you anticipate attending this event?
What is the target audience of this event? (select all that apply)
Elementary school-aged youth
Middle school-aged youth
High school-aged youth
College-aged youth/young adults
Parents
Older Adults ages 60+
LGBTQ+
Professionals
General Public
Other
Event Name
Event Date
-
Month
-
Day
Year
Date
Event Start Time
AM
PM
Event End Time
AM
PM
Event Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please share any additional information about this event (e.g., parking information, etc.)
Evidence-Based Substance Use Prevention Programming
ADAPT offers the following multi-session educational programs designed to prevent substance abuse that have been tested through research and proven effective in reducing substance use behaviors. Please select the programs you are in learning more about.
If interested in learning more about an evidence-based prevention programming, please select all that apply.
Teens in Action (6-week program for tweens and early teens aged 11-16 that teaches important life skills while helping them understand the dangers of risky behaviors such as alcohol and drug abuse)
Active Parenting: First FIve Years (4-week multicultural, video-based discussion program for parents, early childhood staff, and caregivers of children ages birth to 5 that addresses basic skills, the stages of development, and more)
Active Parenting (6-week parenting program helping parents of kids ages 5 to 12 raise responsible, cooperative children who can resist negative peer pressure and thrive)
Active Parenting of Teens (6-week parenting program to help parents through the often tumultuous years of 11-16)
Strengthening Families (14-week science-based family skills training program designed to increase resilience and reduce risk factors for behavioral, emotional, academic, and social problems; program available for parents and their children aged birth-3; 3-5; 6-11; 12+)
Wellness Initiative for Senior Education (6-week wellness and prevention program for adults aged 60+ designed to help them celebrate healthy aging, make healthy lifestyle choices, and avoid substance use)
Where did you hear about us?
Please Select
Search engines (Google, Safari, Bing, etc.)
Social media (Facebook, Instagram, YouTube, etc.)
Online ads (Google Ads, Facebook Ads, Instagram Ads, etc.)
Professional or Colleague
Friend or Family
Email
Other
Submit
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