FASD Center for Excellence

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Fetal Alcohol Spectrum Disorders Center for Excellence

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Conference/Event Speaker Request Form

Required items are marked with an asterisk (*).

I. Contact Information

*First Name: M.I.: *Last Name:

Position/Title:

Organization/Agency Name:

Email Address:

Address Type:

Business Address

Home Address

Address 1:

Address 2:

City:

*State: Zipcode:

*Country:

*Telephone (ex: xxx-xxx-xxxx):

Fax:

How did you hear about us?:

II. General Information

Name of conference/event:

Anticipated date of conference/event:

Conference/event location:

Anticipated time limit/length of presentation:

Conference/event sponsor:

IV. Additional Information

If you are requesting a specific staff member or position, please specify:

Additional Information:

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES - Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention - www.samhsa.gov

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Select here for a toll-free phone number or e-mail address that you can use to submit a question to an Information Specialist at the FASD Center for Excellence.

SAMHSA Awards $1.5 Million to the Choctaw Nation for Residential Substance Abuse Treatment for Pregnant and Postpartum Women (9/26/08)

OB/GYNs encouraged to screen for substance abuse in pregnant women and offer treatment (8/30/08)

Preventing Alcohol, Tobacco, and Other Substance-exposed Pregnancies: A Community Affair (Meeting Sept 23-24)

Substance Abuse Treatment Facility Locator Updated

SAMHSA Awards $66 Million for Programs Teaching Early Intervention Techniques to Use with Patients at Risk for Substance Abuse

Facilitators: Training to teach Triumph Classes to Parents Raising Children with FASD (Mtg March 2009) ((MS Word File))

Line Art showing three pregnant women