Indiana TA Request Form

Indiana Technical Assistance Request form

MM slash DD slash YYYY
Please indicate the population(s) served as it relates to this request
Check all that apply
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.

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