{"id":1212,"date":"2018-02-16T11:14:24","date_gmt":"2018-02-16T16:14:24","guid":{"rendered":"https:\/\/health.uconn.edu\/sbirtinstitute\/?page_id=1212"},"modified":"2026-09-16T13:54:00","modified_gmt":"2026-09-16T17:54:00","slug":"contact-us-form","status":"publish","type":"page","link":"https:\/\/health.uconn.edu\/sbirtacademy\/contact\/contact-us-form\/","title":{"rendered":"Contact Us Form"},"content":{"rendered":"<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use 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class='gform-body gform_body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_1_11\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_11'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container'><input name='input_11' id='input_1_11' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_1_11'>This field is for validation purposes and should be left unchanged.<\/div><\/li><li id=\"field_1_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_1_2\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_2'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_1_2' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_1_6\" class=\"gfield gfield--type-phone gfield--phone-format-standard field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_6'><span class='gform-field-label__text'>Phone<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_1_6' type='tel' value='' class='medium'  placeholder='(999) 999-9999'  aria-invalid=\"false\"   data-mask=\"(999) 999-9999\" \/><\/div><\/li><li id=\"field_1_9\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_9'><span class='gform-field-label__text'>Agency name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_1_9' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_1_5\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_5'><span class='gform-field-label__text'>Type of enquiry<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_1_5' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose from:<\/option><option value='Classroom training' >Classroom training<\/option><option value='In-Company training' >In-Company training<\/option><option value='e-learning' >e-learning<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_1_8\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_8'><span class='gform-field-label__text'>Course title<\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_8' id='input_1_8' class='medium gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose from:<\/option><option value='Addictology' >Addictology<\/option><option value='Brief Treatment (2 day)' >Brief Treatment (2 day)<\/option><option value='Brief Treatment (6 hr)' >Brief Treatment (6 hr)<\/option><option value='Motivational Interviewing' >Motivational Interviewing<\/option><option value='SBIRT for Adolescents (4 hr)' >SBIRT for Adolescents (4 hr)<\/option><option value='SBIRT for Adolescents (8 hr)' >SBIRT for Adolescents (8 hr)<\/option><option value='A-SBIRT Training of Trainers (2 days)' >A-SBIRT Training of Trainers (2 days)<\/option><option value='SBIRT for Adults (4 hr)' >SBIRT for Adults (4 hr)<\/option><option value='SBIRT for Adults (8 hr)' >SBIRT for Adults (8 hr)<\/option><option value='SBIRT Training of Trainers (2 days)' >SBIRT Training of Trainers (2 days)<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_1_3\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_3'><span 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