ADAPT Request Form
Thank you for your interest in ADAPT prevention programming and initiatives! Please complete this form to make your request.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
If you are making this inquiry on behalf of an organization or business, please specify the name.
Name of org/business
What age group or population are you looking to service? Please 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
If you are in need of a prevention resource, please describe what is needed.
If you are interested in having us table at your event, please provide us with details about the event (i.e., date, time, location, estimated number of people, language)?
If you are interested in evidence-based prevention programming, please select all that apply.
We're Not Buying It 2.0 (substance use prevention program for youth in grades 6-8)
PreVenture (mental health prevention program for youth aged 12-18)
Wellness Initiative for Senior Education (program for adults aged 60+)
Strengthening Families (program for parents and their children)
Active Parenting (program for parents and their teens)
If you are interested in receiving information/ literature/ posters about substances, which substance(s) are you interested in? Please select all that apply.
General all substances
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.
Quantity of signs and language
Address where it will be posted
Submit
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