Unity Recovery - Training and Technical Assistance Request Form

Training and Technical Assistance Request Form
Please review and complete the following request form with as much information as possible to facilitate your request. Our T/TA team will be in touch within 48-hours of each request submitted to schedule a discovery call.
Name

First NameLast Name
Pronouns used for communication
Email

Confirmation EmailPlease verify your email address
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred method of communication
Organization Name
Organization Website
Role / Job Title of Requestor
Primary Organization Type

Other
Which best describes the community in which you work? Select all that apply

Other
Who does your organization primarily serve (select all that apply)?

Other
Please select the domain(s) that your request best fits into. Select other and type the topical area if it is not available in this list.

Other
Preferred Event Delivery Channel
How many expected attendees or impacted stakeholders would you estimate being a part of this event?
Who is the intended audience for this request?

Other
Please describe your training and technical assistance needs as specifically and detailed as possible. A useful framework is to identify the barriers or obstacles you are facing (i.e., the problem you are attempting to overcome), the reason the opportunity exists and now is the time to address it, the type of activity you are hoping to use and why, and any other information that can help us understand your current needs.
What do you hope will be different as a result of this training? What do you hope to achieve as an outcome following the delivery of this training in the near, mid, and long term?
Ideal Event Delivery Date and Start Time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
If your request is not covered under federal or state grant funding for the Unity T/TA recovery hub, do you have a budget for your request? Please describe.
Should be Empty: