Thriving Families Registration Form
The Thriving Families Program of the Pitt County Coalition on Substance Use (PCCSU) aims at educating the community of the protective factors for substance use. The trainings that will be a part of this program are on a variety of topics including parent and child communication, trauma and resilience, career readiness, and much more. All trainings are free to the public without filling out this registration form; however, if you would like to receive incentives for participating in this program, this completed form provides PCCSU with the necessary information to determine if you are eligible for those incentives.

For any questions or concerns, please contact Briana, PCCSU's Special Projects Coordinator, at briana@pccsu.org or 252-652-1957 ext. 1005.
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First Name
Last Name
Email
Mailing Address
City, State, Zip code
Phone Number
Have you ever been diagnosed with a substance use disorder? *
How often do you use the following...
Very Frequently
Frequently
Occasionally
Rarely
Very Rarely
Never
Alcohol
Tobacco
Prescription pain killers (not prescribed to you or in ways other than prescribed)
Non-prescription pain killers
Marijuana
Other
If you selected 'other' for the previous question, please name the substance(s).
Which of the following type(s) of training(s) are you interested in?
Please type your name below if you agree with the following statement: I understand that by completing this form, I am enrolling in the Thriving Families program. As a part of this enrollment, I agree to allow Pitt County Coalition on Substance Use (PCCSU) to share my name and contact information, when necessary, with the third parties who will operate the trainings utilized in this program.  
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