Fetal Alcohol Spectrum Disorders - Center For Excellence

24/7 Treatment Referral Line 1-800-662-4357

1-866-STOPFAS
(786-7327)

SAMHSA is an Agency
of the U.S. Department
of Health & Human Services

Vermont Departament of Health Launches “049” Campaign

Report reveals special challenges of pregnant teens in substance abuse treatment

Technical Assistance Request Form

I. Contact Information

Salutation:

First Name:

Middle Initial:

Last Name:

Position/Title:

Organization/Agency Name:

E-mail Address:

Address Type:

Business Address
Home Address

Address 1:

Address 2:

City:

State:

Zip Code:

Country:

Phone: (e.g. 301-555-1212)

Fax: (e.g. 301-555-1212)

How did you hear about us?

II. General Information

Anticipated date of technical assistance:

Technical assistance location:

Anticipated length of technical assistance:

III. Brief Description

Brief description of organization/agency/group requesting the technical assistance:

IV. Purpose

Purpose of the technical assistance or brief history of the problem:

V. Expected Outcomes

Expected outcomes of the technical assistance:

VI. How will the Learning be Incorporated

How will the Learning be Incorporated:

Do you anticipate needing some follow-up support from the Center:

Yes
No
Unknown

VII. Potential Topics

Potential technical assistance topics (Please check all that apply): *

Conducting a Town Hall
Designing/Implementing a Prevention Campaign
Designing/Implementing Treatment Approaches
Developing a State/Community/Organizational Plan
Developing/Implementing Program Evaluation
Establishing an FASD Task Force
Integrating FASD into an Existing System
Intervening with Women at Risk
Materials Development
Strategic Planning
Other

Other (description):

VIII. Additional Information

Additional Information:

1-866-STOPFAS(786-7327)

SAMHSA is an Agencyof the U.S. Departmentof Health & Human Services

Technical Assistance Request Form

1-866-STOPFAS
(786-7327)

SAMHSA is an Agency
of the U.S. Department
of Health & Human Services