Co-Occurring Disorders Application
Please complete the form below.  Upon acceptance into the training, you will receive training login details via email.  Thanks for applying!
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What is the first day of the training you are interested in attending? *
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/
MM
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DD
First Name *
Last Name *
Name as you would like it to appear on your certificate of completion *
Are you an IC&RC Certified Recovery Coach? *
Email *
Phone Number *
Street Address *
Street Address Line 2
City *
State *
County *
Zip Code *
What Recovery Center do you work with? *
If other, where are you working or volunteering? *
Have you completed the Vermont Recovery Coach Academy? *
If yes, when did you complete the Academy? *
Does your supervisor formally recommend your attendance at the Co-Occurring training? *
Supervisor's Name *
Supervisor's Email *
Supervisor's Phone Number *
How did you hear about this training? *
Why do you want to be considered for this training? (500 word max)
 *
Do you require any special accommodations and/or would you like the facilitator to know anything about your needs and/or learning styles?
 *
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