Prevention Programs Request Form
Please fill in the following information to request a presentation or activity from The Council's Prevention Programs.
When possible please allow a minimum notice of two weeks prior to the date requesting to better help us meet your need.
If you have any trouble with this form please email:
b.tinney@recoverycouncil.org
Thank you.
* Required
Organization Name
*
Your answer
Which county are you in?
*
Please select ALL that apply.
Collin
Cooke
Dallas
Denton
Ellis
Erath
Fannin
Grayson
Hood
Hunt
Johnson
Kaufman
Navarro
Palo Pinto
Parker
Rockwall
Somervell
Tarrant
Wise
Other:
Required
Name
*
Your answer
Title
Your answer
Email
*
Your answer
Phone number
*
Your answer
Activity
*
Presentation
Career Day
School Assembly
Health Fair/ Resource Fair
Other:
Location/ Facility
*
Please include address as well as the name
Your answer
Date(s) requesting
*
If you do not have a specific date please provide the best day of the week. Also provide when you want the presentation (i.e. a specific week in March).
Your answer
Time
*
If you do not have a specific time please provide the best time of day. Also include how long the presentation/activity will be (i.e. 45 minutes)
Your answer
Audience
*
Please select ALL that apply
Parents
Students
Faculty/Staff
Community Members
Other:
Required
If this activity is for students, please indicate which grades below.
Your answer
If this activity is for Faculty/Staff please indicate if they need Continuing Education for any of the following:
Please select ALL that apply
LPC
LMSW
LCDC
LMFT
No CEUs needed
Presentation Topic
* If this is for a presentation request, please select ALL that apply.
General Drug Education
Prescription Drugs
Alcohol: Underage Drinking
Marijuana
Synthetic Drugs
Illicit Drugs
Tobacco and Electronic Cigarettes
Latest Drug Trends
Bullying
Other:
If this is for a Resource or Health Fair, please check ALL that apply:
Indoor Booth
Outdoor Booth
Table is provided
Chair is provided
Tent is provided
Other:
If this is for a presentation, assembly or other activity, please indicate what technology accommodations you can provide.
This is for our planning purposes. Our Prevention Specialists need to know whether to bring a laptop or just their USB drive with their presentation. Please select ALL that apply
Computer
Projector
Projection Screen
Speakers
Microphone (if needed)
Internet Access
None of the above
Additional Information
Your answer
Submit
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