Which class do you need to register for?* BASICS CASICS Name* First Last Email Gender Male Female Mobile Phone*Other PhoneCampus Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Student ID* Date of Birth (YYYY-MM-DD)* YYYY dash MM dash DD Year in SchoolFreshmanSophomoreJuniorSeniorCompletion Deadline* YYYY dash MM dash DD Was marijuana also involved in this incident?* Yes No Have you completed CHOICES about alcohol group previously?* NO - referred directly to individual BASICS YES - completed CHOICES at Connections YES - completed CHOICES at Tellurian Have you completed CHOICES about alcohol group previously?* NO - referred directly to individual CASICS YES - completed CHOICES at Connections YES - completed CHOICES at Tellurian Have you completed individual BASICS (alcohol) previously?* NO - referred directly to individual CASICS YES - completed BASICS at Connections YES - completed BASICS at Tellurian Was alcohol involved in the current incident?* Yes No Maybe Were you referred for CASICS+ (marijuana and alcohol)* Yes No Referred by:UW Dean of StudentsUW Student HousingMadison Police DepartmentUW Police DepartmentOther referral sourceName of referring individual Referring individual email address Ethnicity self-identification (voluntary) Hispanic or Latino White (Not Hispanic or Latino) Black or African American Native Hawaiian or other Pacific Islander Asian American Indian or Alaska Native Two or more races listed above Ethnicity not self-identified Total $0.00 Payment must be made before first session. Provide your VISA or MASTERCARD information to charge session cost of $125. Following registration and payment you will be contacted by Connections Counseling to schedule your first individual BASICS session. First contact will be by email. Payment may also be made by telephone (608-233-2100 x-0 Mon-Thur 9 am to 7 pm and Friday until 3 pm) or in person at Connections Counseling LLC, 5005 University Ave, Ste 100, Madison 53705.Billing Name (if not your name) First Last Billing Zip Code (if not your campus address) ZIP / Postal Code Any addition information we should know? Include schedule preference (day of week, time of day)?