ADAPT Program Request Form

1. Contact Person Name:

2. Organization Name:
3. Requested Program:
  1. Alcohol and Drug Program (Fulfills FOA Requirement)
  2. Social Norms, Alternative Activities, Resources for Low-Risk Drinkers
  3. Intervention Techniques, Enabling, Codependencey
  4. Differences in alcohol's effect on men and women, impact of the loff os inhibitions and judgment for women  
  5. Enabling, Problem Drinking, Intervention Techniques

4. For Alcohol and Drug Program Requests :

Please list specific drugs which you want the program to target (eg. marijuana, cocaine, mushrooms, prescription drugs, ecstasy, etc.)

5. Dates and Times of Requested Program (Please List Three Different Dates with Different Times)

6. Number of Participants:
7. Contact Person Email:
8. Contact Person Phone Number: