Treatment Professional Registration Form

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* 1. Registration type:

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* 2. Personal contact information:

First and Last Name

Company (required)

Address

City/Town

County

State/Province

Postal Code

Country

Email Address

Phone Number
(i.e. 555-123-4567)

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* 3. What is your role?

Treatment professional using SMART with clients

Other (describe below):

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* 4. Completion Date? (Enter Completion Date from your completion certificate.)

	Month	Year
Completion Date: (GSF MM-YYYY)	Completion Date: (GSF MM-YYYY) Month menu	Completion Date: (GSF MM-YYYY) Year menu

If you completed training prior to 2006 or an onsite training, please provide details below.

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* 5. SMARTCAL is a discussion group for all SMART Recovery volunteers and is the primary means of communication between volunteers, the Board of Directors, and the Central Office. It is also a place to pose questions regarding any organizational, meeting, or other issues.

Yes, please subscribe me to SMARTCAL.

No, I do not wish to subscribe to SMARTCAL.

If you prefer SMARTCAL messages to be sent to an email address different from the one listed above, please provide it here.

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* 6. SMARTTxPro is a discussion group you can subscribe to if you are a certified addiction treatment professional, where you can communicate with other treatment professionals serving SMART Recovery.

Yes, please subscribe me to SMARTTxPro

No, I do not wish to subscribe to SMARTTxPro

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* 7. Additional skills/expertise I'm willing to share with SMART (optional):

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* 8. Special instructions (if any):

Failure to completely fill out this form will result in processing delays. Please allow 3 - 4 weeks for processing time.

Upon completion, please send an email to vrf@smartrecovery.org to notify us your registration has been submitted. THANK YOU!