ADAPT Technical Assistance Request Name* HiddenTitle of HIDTA Prevention Representative* Email* Enter Email Confirm Email Phone Number*Organization/Agency Name* HIDTA Region, if known Address City State / Province / Region ZIP / Postal Code How can we help you?*Technical Assistance Category* Select All Training Identification of Best Available Evidence Implementation Evaluation Fiscal/Budget Sustainability Early Response Prevention Communications Systems Development Other If other, please specify: HiddenFile for TA RequestNot required, but you may upload a separate document if needed.Max. file size: 16 MB.HiddenAmount of HIDTA funding received for project* HiddenTarget population (check all that apply)* Birth – 3 Youth 4-12 Adolescents 12-18 Young Adults 18-25 Adults 25+ HiddenGeographic Area of Responsibility* Rural Urban Combination HiddenPlease include a brief description, including goals of the funded prevention project requesting TA (may attach as a separate document if needed)*HiddenFile for DescriptionNot required, but you may upload a separate document if neededMax. file size: 16 MB.CAPTCHACommentsThis field is for validation purposes and should be left unchanged.