Adult COD Registration WIMHRT Logo

Application Form for
Case Management Academy for Adults with Co-occurring
Mental and Substance Disorders
1) Name:
Mr.      
Ms.  Lastname  First
2) Address
 City  State  Zip
3) Home Phone:
( )
 
AreaCode
Number
4) Email Address:
5) Highest Degree Received:
GED   HS AA LPN  
RN BA/BS   MA/MS   Other 
6) How long have you worked in the:

Mental Health Field

Years Mo

CD Field

Years Mo

Aging Field

 Years Mo
 
7) How long have you worked in
your current position? 		Years Months
8) Current Position Title:
9) Do you work primarily with:
Adults
Children
Crisis Services
Elderly
Homeless
Inpatient population
10) Description of your current Duties:
11) Agency Name:
12) Agency Address:
City State Zip
13) Agency Phone:
( )
   
AreaCode
Number
Ext.
14) Fax:
( )
 
AreaCode
Number
15) Special Needs:
(please describe)
 eg, special diets, wheelchair access, etc.  
16) My Supervisor is:
Lastname First
17) My Supervisor's
Phone Number is:
( )
 
AreaCode
Number

Please Print and Fax this form to: Diane Pearson (Program Coordinator)
Fax: (253) 756-3987
Tel: (253) 756-2741          Email: pearsond@u.washington.edu

NO TELEPHONE RESERVATIONS, PLEASE.