Adopt SBIRT Registration

Name*

First Last

Credentials

Agency/Organization*

Current Position*

Physician
Physician Assistants
Nurse Practitioners
Nurse
Social Workers
Addiction Counselors
Peer Recovery Support Positions
Prevention
Other (describe)

Describe Your Current Position*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Mobile Phone Number*

Email*

Enter Email Confirm Email

Password*

Enter Password Confirm Password

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How did you learn about this event:*

Are you currently implementing SBIRT in your organization and/or practice?*

Yes
No

Do you have a background or have you attended SBIRT training?*

Yes
No

If Yes, Please Explain*

What do you hope to learn by taking the SBIRT-IP Workwise Series?*

By checking here you are indicating that you understand the technology requirements and participant commitment as follows:*

• Access to appropriate technology to utilize online videoconferencing platform (i.e., an internet connection, built-in or USB webcam, laptop/tablet, built-in/USB/Bluetooth speakers and microphone) • Prior to the Orientation session, view a 20-minute tutorial on how to use the videoconferencing platform • Attend a one-hour online Orientation Session on the scheduled date and time • Commit to 6-weeks of training for 1.5 hours weekly on scheduled series days/times. Participants are expected to be visible on camera 90% of the scheduled series time to earn the weekly 1.5 CE. • Complete one-hour of weekly self-study learning activities and participate in discussions during the weekly sessions verbally or via chat during the scheduled series days/times in order to receive the one-hour weekly learning activity CE.

I understand the time commitment involved and agree to fully participate.

SBIRT - Adopt SBIRT 3.1