PRINT THIS 1 PAGE FORM

 

REUNITED VIDEO ORDER FORM

This video regarding ASFA is ONLY for parents entering the child welfare system largely due to meth related problems.† This is not a pharmacology video or a drug lab video. This video is not for kids, police officers, preventionists or others not directly in contact with ASFA parents.

 

Where do you want us to send the video?

 

Name of agency_________________________________________________

 

Your Name ____________________________________________________

 

Address _______________________________________________________

 

______________________________________________________________

 

State_______________††††††††† Zipcode (5 digits)____________________

 

Phone: _____________________________________________

 

Do you want it on DVD or VHS Tape?† (if you order it on DVD it will only play on a DVD player, it will not work on a CD player or on a computerís CD Drive, it will work on your computer if your computer has a DVD drive built in, look on the front of the drive if youíre not sure.† If it doesnít say DVD on the front of the drive then it does not play DVDís)

 

Check one of the following:

 

_________VHS Tape†††††††††††† __________DVD

 

Make check or money order payable to Eric Martin, M.A., CADC III

Mail this form along with your check or money order for $21.95 to:

 

Eric Martin, M.A., CADC III

2054 N. Vancouver Ave.

Portland, Oregon† 97227

 

Once the order is received, your video will be mailed within 72 hours!

Contact information:

Eric Martin, M.A., CADC III

Executive Director, Addiction Counselor Certification Board of Oregon

Instructor, University of Oregon and DHS Child Welfare

(503)231-8164

Eric@ACCBO.com

 

If you desire training in your area, please contact Eric Martin regarding the following 1-day courses (accredited by NAADAC, provider # 000182)

ō       Treating Marijuana Dependence

ō       Methamphetamine Addiction Treatment Best Practices and Child Welfare

These trainings have been presented in Oregon, Washington, Alaska, Montana, and Idaho