Indiana TA Request Form Indiana Technical Assistance Request formName First Last Date MM slash DD slash YYYY OrganizationAddress City State / Province / Region ZIP / Postal Code Email PhonePlease 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 AllCheck all that applyOther: Please SpecifyPlease 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 submissionFollow 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
