NASW NYC 35th Annual Addictions Institute
at Fordham University, Lincoln Center
Wednesday, May 21, 2003

"The Interplay of Addictions and Psychiatric Disorders:
Implications for Social Work Practice."

Workshop Proposal Submission Form
All information must be completed. Please type or print.
All workshops are two hours in length.

Workshops will be accepted if submitted on this form only.

Moderator must be designated and must be a social worker.

Proposed Workshop Title:___________________________________________________________________

Lead Presenter (to receive all correspondence):

__________________________________________________________________________________________

Mailing Address: ____________________________________________________________________________

Home Phone: _______________________________________________________________________________

Work Phone: _______________________________________________________________________________

E-Mail**: _________________________________________________________________________________

**Email will be the primary method of communication, please include email address(es) or indicate "none" and provide fax/mailing address**

Brief Description of Presentation (maximum 75 words)
Note: Description must be in narrative form, may be edited, and will appear in conference brochure.
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Style:                           ____ Workshop                        ____ Research Paper

Audio-Visual Needs:              ____ VCR/Monitor                     ____ Overhead Projector       
                                 ____ Blackboard                      ____ LCD Projector (availability limited)


Preferred workshop time:        ____ Morning (9:15 a.m. to 11:15 a.m.)       ____  Afternoon (2:30 p.m. to 4:30 p.m.)

The NASW Addictions Institute Planning Committee reserves the right to designate final workshop time.

List all participants and their address and credentials. All information must be completed. Please do not abbreviate affiliations. **This information will be printed in the conference brochure.** In listing yourself, please indicate whether you will be a speaker as well as a moderator, by checking the appropriate box. The moderator or at least one speaker must have a social work degree. Please note, curriculum vitae must be submitted from moderator and all speakers. This is needed to facilitate CEU accreditation of all workshops.

 
Moderator or Moderator/Speaker. (circle one) Note: MUST HAVE SOCIAL WORK DEGREE.
Moderator Name (Please print): ____________________________________________________________________

Credentials (e.g. CSW, CASAC): ___________________________________________________________________

Primary Affiliation with title (e.g. Director, Psychiatry, St. Elsewhere Hospital):

______________________________________________________________________________________________

Secondary Affiliation: (e.g. private practice) __________________________________________________________

Mailing Address: ________________________________________________________________________________

Preferred Phone: ________________________________________________________________________________

Fax: _______________________________________________________________________________

Email**: ____________________________________________________________________________

**Email will be the primary method of communication, please include email address(es) or indicate "none" and provide fax/mailing address**




Note: If lead presenter is the sole speaker, a moderator who is a social worker MUST be named on this form.

Speaker 1 Name (Please print): ____________________________________________________________________

Credentials (e.g. CSW, CASAC): ___________________________________________________________________

Primary Affiliation with title (e.g. Director, Psychiatry, St. Elsewhere Hospital):

______________________________________________________________________________________________

Secondary Affiliation: (e.g. private practice) __________________________________________________________

Mailing Address: ________________________________________________________________________________

Preferred Phone: ________________________________________________________________________________

Fax: _______________________________________________________________________________

Email**: ____________________________________________________________________________




Speaker 2 Name (Please print): ____________________________________________________________________

Credentials (e.g. CSW, CASAC): ___________________________________________________________________

Primary Affiliation with title (e.g. Director, Psychiatry, St. Elsewhere Hospital):

______________________________________________________________________________________________

Secondary Affiliation: (e.g. private practice) __________________________________________________________

Mailing Address: ________________________________________________________________________________

Preferred Phone: ________________________________________________________________________________

Fax: _______________________________________________________________________________

Email**: ____________________________________________________________________________




Speaker 3 Name (Please print): ____________________________________________________________________

Credentials (e.g. CSW, CASAC): ___________________________________________________________________

Primary Affiliation with title (e.g. Director, Psychiatry, St. Elsewhere Hospital):

______________________________________________________________________________________________

Secondary Affiliation: (e.g. private practice) __________________________________________________________

Mailing Address: ________________________________________________________________________________

Preferred Phone: ________________________________________________________________________________

Fax: _______________________________________________________________________________

Email**: ____________________________________________________________________________
Form must be submitted with all CV's by November 15, 2002.
Proposals recevied with incomplete or illegible information will not be considered.

Mail the following items:
  1. This form with all information completed, including 75-word abstract in narrative form, moderator or moderator/speaker who is a social worker, credentials and affiliations of all presenters (moderators and speakers), with all presenters' contact information
  2. Curriculum Vitae of moderator and all speakers. This is needed to facilitate CEU accreditation of all workshops.
Mail all materials required to:
Dan Pitzer
651 Monmouth Ave
Port Monmouth, NJ 07758
breakingthechain@earthlink.net