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Indiana TA Request Form
Indiana Technical Assistance Request form
Name
First
Last
Date
MM slash DD slash YYYY
Organization
Address
City
State / Province / Region
ZIP / Postal Code
Email
Phone
Please Briefly explain the area of focus for this technical assistance request.
Please indicate the population(s) served as it relates to this request
People with disabilities/a disability
People who are deaf or hard of hearing
People who are blind or have low vision
People with an intellectual or developmental disability
People who use a wheelchair or mobility device
People experiencing homelessness
People experiencing poverty
People with undocumented status
Older adults
Rural communities
LGBTQIA+ Individuals
People experiencing crisis or trauma
People with a pre-existing mental health diagnosis
People who use drugs
People in recovery from Substance Use Disorder
Select All
Check all that apply
Other: Please Specify
Please select which of the following best describes your current job. If your job responsibilities are split between multiple roles, select the category that fits the majority of your job responsibilities.
Peer Recovery Coach
Program Coordinator
Program Director
Executive Director
Board Member/Volunteer
Other
Please provide any additional information that would help Faces & Voices of Recovery to best support this request (Optional)
Thank you for your submission
Follow up coorespondence will be sent to your email. If you have any questions, please contact Krissi Jacob, Recovery Support Services Specialist at kjacob@facesandvoicesofrecovery.org
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