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ETELA Network Interest Form
If you are a professional or community leader that is interested in 1) helping to form a new End the Epidemic LA network in your area or 2) collaborating with ETELA as an existing rural local group, please submit the information below. For questions or concerns, contact Program Coordinator Rachel Jackson at
rachel@louisianaambulancealliance.org
.
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Email
*
Your email
Name
*
Your answer
Choose the description(s) below that most accurately describes your professional title dealing with opioid use disorder.
*
Family member or caretaker
Professional addiction or recovery practitioner
Social worker
Mental health counselor
Religious organization representative
Educator or Academic Administrator
Non-profit or support organization representative
State or local agency representative
First responder or law enforcement representative
General public/Concerned citizen
Required
What city or town do you primarily work in?
*
Your answer
Do you represent an existing community health OR opioid resource group, network, or coalition? If so, name your group here. Feel free to also provide website links or other information.
Your answer
How would you like to work with End the Epidemic LA?
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Form an ETELA network in your area with other rural local professionals from different industries
Work with your existing local rural network to collaborate with ETELA
Partner with ETELA on a specific outreach initiative or event
Request opioid epidemic educational materials and/or speakers
Other:
Required
If you have any other specific requests, questions, or concerns about working with ETELA, list them here.
Your answer
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