Peer Exchange Interest Form

Point of Contact Name *

First Name

Last Name

Point of Contact Phone Number *

Country

(###)

###

####

Check the boxes that best describe the current status of medication assisted treatment in your facility. *

Select all that apply

We continue individuals on medication assisted treatment if they enter the facility with an existing prescription

We induct individuals onto medication assisted treatment while they are in custody

We do not currently have medication assisted treatment in our facility

Other

Please check the mentor site(s) you feel you may best learn from. *

Select all that apply. Visit our Peer Exchanges page for more information on the host sites.

January 2026 | Fairfax County, VA

March 2026 | Pinal County, AZ

July 2026 | Clackamas County, OR

September 2026 | Franklin County, MA

January 2027 | LaSalle County, IL

March 2027 | South Correctional Entity (SCORE), WA

Chesterfield County, VA

Essex County, MA

Hampden County, MA

Middlesex County, MA

Proposed Attendee #1

First Name

Last Name

Proposed Attendee #2

First Name

Last Name

Proposed Attendee #3

First Name

Last Name

How did you learn about COSSUP's TTA and Mentor Site Visit Initiative? *

Please choose all that apply.

We are a current COSSUP grantee

Training/Conference

National Sheriffs' Institute

Other