First Name*

Last Name*

Credentials (as you would like them to appear on certificates and conference related publicity)

Address*

City*

State*

Zip Code*

Email*

Phone*

Phone 2

Credentials: (Please write a biographical sketch and/or copy and paste your vitae/resume in the space below.)*

Please explain how this workshop contributes to the advancement or enhancement of professional skills and knowledge of substance abuse counseling/social work. (2 – 5 sentences)*

Topic of Workshop:*

Title of Workshop: (The title you would like to appear on the certificate and conference related publicity) *

Please state (in measurable terms) at least 3 proficiencies the participants will receive from your instruction. Example (Fictional workshop): “Street Outreach for Beginners” Participants will be able to: 1. Use a decision-making model to anticipate and plan appropriate responses to crisis situations during outreach 2. Create a community map for a target outreach community 3. Identify possible barriers to reaching outreach populations and ways to overcomes these barriers Participants will be able to: *

Please give a short description of your workshop for the conference program. (3 – 10 sentences) Workshop description should cover: • The key elements of the subject content • The necessary background needed by the participant to best understand the information (i.e., suitable for beginners, participants should have some treatment experience, open to everyone, etc.) • A summary of the learning objective of the workshop Example (Fictional workshop): “Street Outreach for Beginners” -- The objective of this session is to acquaint participants with the “do’s” and “don’ts” of Street Outreach. Appropriate skills, information, roles, and expectations will be covered. This workshop is appropriate for beginning Street Outreach Workers or their administrators who want to develop an orientation for new staff. (3 sentences) Workshop description: *

Teaching methods utilized during the presentation (check all that apply):

By checking yes below, I verify that I am currently certified/licensed in my area of expertise, and/or can show evidence of specialized training and/or experience in the last five years of this subject matter, and am free from any disciplinary action by the Ethics/Standard Committees or any other credentialing committees.*