Member Organization Interest Form

Important Note: (*) denotes required information. Please make sure to complete these.

Organization Name *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Description *

Job Based Name

Website / URL *

Contact Name *

First

Last

Job Title *

Phone *

Email *

Type *

Services *

• Peer support
• Peer support: Quick Response Team(s)
• Peer support: Recovery Coaching
• Peer support: Recovery resource dissemination
• Pro-social events
• Virtual recovery support
• Telephone recovery support
• Adolescent peer support services
• Support groups
• Family recovery support services
• Re-Entry support services
• Housing support services
• Employment services
• Education
• Life skills training
• Medicated Assisted Recovery
• Naloxone training and distribution
• Domestic violence recovery support
• Veteran recovery support
• Mental Health peer support services
• Faith-based recovery support
• Problem gaming recovery support services
• Smoking cessation recovery support services
• Wellness
• Other

Please choose all that apply

Other Service *

Program Based (faith-based or secular) :

Submit