SBIRT Training Registration Form
Understanding SBIRT: Foundations, Implementation, and Clinical Practice
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Full Name *
Email Address *
Title *
Company Name *
Work Address *
City *
State Code (e.g., GA) *
Zip/Postal Code *
Work County *
Do you work in a primary care setting? *
(A primary care setting is a facility that provides integrated, accessible health services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.)
Do you work in a Medically Underserved Community (MUC) setting? *
(A Medically Underserved Community (MUC) Setting is a geographic location or population of individuals that is eligible for designa-tion by a state and/or the federal government as a health professions shortage area (HPSA), medically underserved area (MUA) and/or medically underserved population (MUP). These communities have limited access to primary health care services. The term MUC is an umbrella term that can be used to describe any location that meets one or more of the previously identified designations.)
Do you work in a rural setting? *
(A rural setting is a geographical area that is not part of a Metropolitan Statistical Area (MSA). A MSA is an area that contains a core urban area of at least 10,000 population.)
Which of the following best describes your profession and discipline? *
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