AGENCY REGISTRATION

Agency name:*
Point of contact:*

First NameLast Name
Phone number of point of contact:*
Please enter a valid phone number.
Point of contact email:*
example@example.com
Requested training type:*
Requested location of training:*
Branches LLC can offer accommodations for the training; fees for a location will be discussed upon call consultation.
Please input your preferred date/time for the training below. Add multiple date/times if many options are available for your agency.
Requested date and time:*
Branches LLC can offer meals/refreshments for the training; fees for this service will be discussed upon call consultation.
Requested meals/refreshments:*
Any dietary requirements or special needs? List below.
List any special food needs if you will be having Branches provide the meal.
The creator of this training program, the Addiction Policy Forum, requests we submit a participant list that includes email addresses for purposes of sending a PRE and POST survey ONLY. They do not use these emails for any purpose beyond continued data collection surrounding the program’s impact. IF POSSIBLE, please attach participant list with emails here. If no roster is submitted, it’s assumed permission is granted for Branches LLC to only submit the agency point of contact‘s email to AFP. If a roster is submitted, it is assumed permission has been granted to release all participant names and emails to AFP.
Please list each attendee, email address and License number if applicable. If any attendee will require CEU's, they will need to report their license number here. Ohio Counselor, Social Worker and Marriage and Family Therapist Board and Ohio Chemical Dependency Professionals Board approved provider.
Attendee List*
Are you okay with your scheduled training being advertised on social media or other sites utilized by this agency or it's partner, the Mental Health and Recovery Services Board of Allen, Auglaize and Hardin Counties?*

YesNo
Are you willing to allow outside participants to attend your training?*

YesNo
If answered "yes" to allowing outside participants, please provide any instructions to forward to potential participants:
How did you hear about these training opportunities?*
Should be Empty: