Join the Trilogy Network of Care Presenter Database

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  1.   Enter up to 3 Certificates/Degrees
  1. The information that you provide below will only be reported in aggregate or summary form
  2. Your participation in completing this survey is entirely voluntary
  3. There are no negative consequences to you should you decide
  4. not to complete this or any other questionnaire
  5. Personal Code First Letter of Mothers First Name
  6. Personal Code First Letter of Mothers Maiden Name
  7. Personal Code First Letter in State of Your Birth
  8. Personal Code First Letter in the City of Your Birth
  9. Years of Experience in Addictions

  10. Current Job Title
  11. Primary Discipline or Profession













  12. My area of specialization is
  13. I spend at least 50 percent of my time working with the following groups Check ALL that apply



  14. Primary Work Setting Check ALL that apply













  15. Certification in Addictions Field



  16. Please specify one of the following as your primary role










  17. Gender
  18. I spend at least 50 percent of my time working in the following places Check ALL that apply












  19. Highest Degree Status







  20. Race or Ethnicity






  21. I consider myself ever to have been from an economically disadvantaged background
  22. I consider myself ever to have been from an educationally disadvantaged background
  23. Birth Year 19__
  24. Location of your work or practice County City State Zip
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