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Closing
June 18, 2021
4:15 PM PDT - 4:30 PM
Step
1
of
2
50%
What is your gender?
Male
Female
Transgender
None of these
2. What is your race? (Select one or more):
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White
3. What is the highest degree you have received? (Select one):
Less than high school
High school diploma or equivalent (GED)
Some college, but no degree
Associate’s degree
Bachelor’s degree
Master’s degree
Doctor of Pharmacy (PharmD)
Doctor of Medicine or Doctor of Osteopathy
Other Doctoral degree or Equivalent (e.g., PhD, EdD, DPT)
Other
4. What is your primary profession? (Select one):
Addictions Professional
Psychiatrist
Psychologist
Counselor
Social Worker
Recovery specialist
Peer professional
Criminal justice/law enforcement professional
Community health worker
Health educator
Educator
Public or Business Administrator
Researcher
Physician
Physician Assistant
Nurse
Pharmacist
Advance Practice Registered Nurse
Nurse Practitioner
Nurse Midwife
Dentist
Student Full-time
Student Part-time (not working)
Student Part-time (working)
Other
5. What is your principal employment setting? (Select one):
Substance use disorder treatment program
Substance use disorder prevention program
Community recovery support program
Group home
Transitional/supported living facility
Mental health clinic or treatment program (Community mental health program)
Community health
Primary care
Solo practice
Group practice
Hospital
FQHC hospital
State psychiatric hospital
Skilled nursing facility
Criminal justice/corrections (court, prison, jail, prison/probation, TASC)
Military/VA
Higher education setting
Elementary or secondary education setting
Community-based organization (including faith-based organizations)
Community coalition
Other
6. What is the ZIP Code of your principal employment setting?
ZIP Code
7. How satisfied were you with the overall quality of this event?
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
8. I expect this event to benefit my professional development and/or practice.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
9. I will use the information gained from this event to change my current practice.
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
10. I would recommend this event to a colleague.
Yes
No
Personal Code (please use uppercase letters):
First letter in mother’s name:
First letter in mother’s name:
First letter in mother’s maiden name:
First letter in mother’s maiden name:
First digit of Social Security number:
Please enter a number from
0
to
9
.
First digit of Social Security number:
Last digit of Social Security number:
Please enter a number from
0
to
9
.
Last digit of Social Security number:
CEU Completion/Issuance Form
Would you like a certificate of completion?
(Required)
Yes
No
Email
(Required)
Name
(Required)
I confirm I attended:
(Required)
The Entire Conference
Part of the Conference
Please select sessions attended for issuing CEUs.
(Required)
Day 1- Welcome & Kick-Off
Day 1- Keynote
Day 1- Recovery Advocacy in the Age of COVID-19 or Grief While In Recovery
Day 1- Multiple Pathways of Recovery or Creating a Healing Community
Day 1- Plenary Panel: Whats the Difference?
Day 1- Survivor Insights or "We Do More than Listen"
Day 1- Recovery Messaging or RCO Best Practices
Day 1- Closing
Day 2- Welcome & Kick-Off
Day 2- Keynote
Day 2- Building and Maintaining a Successful Recovery Community Organization (RCO) or Grant Writing Tips & Tools
Day 2- Justice Involved or Recovery Rejection
Day 2- Plenary Panel: This is Us!
Day 2- Unicorns, Rainbows and Glitter Ponies or CRAFT Connect
Day 2- Basics of Successful Fundraising or Disaster Looming
Day 2- Closing
