ADAPT Request Form

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 NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I am a:
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.

Other
Please describe the resource(s) you need.
Substance Use Prevention Information
If requesting information about substances, please select which topic(s) you need.

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

CityState / Province

Postal / Zip Code
Community Fair / Event

If you would like us to table at your event, please complete the following information.
Event Name
Event Date

MonthDayYear
Date
Event Start Time Event End Time
Event Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where does this event take place?
Are table and chairs provided?
What is the target audience of this event? (select all that apply)

Other
How many people do you anticipate attending this event?
Please provide parking instructions.
Please share any additional information about this event.
Speaking Engagement

To request a speaker for your event, please complete the following information.
Event Name
Event Date

MonthDayYear
Date
Event Start Time Event End Time
Event Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of speaker needed (select all that apply)

Other
Presentation for Youth
Presentation for Families
Presentation for Professionals
How many people do you anticipate attending this event?
What is the target audience of this event? (select all that apply)

Other
Your organization's WiFi name and password to connect to on the event day
Please provide parking instructions.
Please share any additional information about this event.
Evidence-Based Substance Use Prevention Programming

ADAPT-SFB 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.
Where did you hear about us?
Should be Empty:

ADAPT Request Form

Resources

Substance Use Prevention Information

Metal Signs

Community Fair / Event

Speaking Engagement

Evidence-Based Substance Use Prevention Programming