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Recovery Hub Region 5-Technical Assistance Request

Please review and complete the following request form with as much information as possible to facilitate your request. Our Region 5 Recovery Hub Project Coordinator will respond within 48-hours of each request submitted to schedule an initial meeting.
1.What is your last name?
2.Pronouns Used?
3.Email?
4.Phone Number?
5.What is your county of residence?
6.Preferred method of communication?
7.Where do you reside?
8.Organization Website
9.Job title of requestor?
10.Organization Type?
11.Which best describes the community in which you work? Select all that apply
12.Who does your organization primarily serve? Select all that apply.
13.Please select the category that your request best fits into.
14.How would you like to meet?
15.Please define your training and technical assistance requirements as specifically and thoroughly as possible. Please identify your plan, any barriers you are facing, and what needs you may have along with any other details you feel are necessary.
16.What is your first name?