Information Request Form for Professionals

	I would like to receive news from Al-Anon Family Groups. (Our distribution list is confidential and is not made available to any other individual or entity. It is used for the sole purpose of providing you with information that may be helpful to you and your clients/patients.)
	Please send a free packet of materials including a catalog.
	Please have a local Al-Anon member contact me to provide information about Al-Anon in my community.

All fields are required

Name:

Title/Position:

Organization:

Street Address:

City:

State/Province:

Zip/Postal code:

Country:

Please select one of the following:
United States
Canada
Bermuda

Daytime Phone:

( ) Ext.

E mail:

Which one of the following fields do you work in?

	Medical (physician, nurse, all medical professionals not specializing in mental health or addiction)
	Mental Health (therapist, counselor, psychologist, psychiatrist, clinical social worker, mental health professionals not specializing in addiction treatment)
	Addictions (professionals who specialize in the field of substance abuse)
	Religious (clergy, church administrator, counselor)
	Education (professor, teacher, school counselor, school administrator)
	EAP/HR (EAP counselor, personnel manager, human resource professionals)
	Other