Please submit this form and email requested documents to complete your application.

Eligibility Requirements:

  1. Completion of an  ACGME, RCPSC, or CFPC accredited residency training program in Family Medicine or Internal Medicine
  2. Board certified or planning to be become board certified (before fellowship start date) in Family Medicine or Internal Medicine
  3. Must be eligible to receive a Wisconsin License and Federal DEA
  4. Must be eligible to be a Medicaid and Medicare Provider

Section 1

Please enter your first, middle, and last name.

Section 2

Please submit the following to and

1. A curriculum vitae which includes:

  • Educational background from undergraduate training onward
  • Specialty certifications and activities, including those in complementary medicine modalities
  • Licensure information—including any restrictions or history of restrictions
  • DEA license—active? License to prescribe buprenorphine?
  • Employment history and military service
  • Honors and awards
  • Community service and volunteer work
  • Publications
  • Presentations
  • Hobbies, interests, and what gives your life meaning
2. An essay of 750 words or less which should provide us with:
  • A sense of who you are - e.g., interests, passions, a description of what gives your life meaning
  • Your reasons for applying for this fellowship
  • Your past experiences with substance-related disorders
  • How you would like to use this training in your professional life
  • Any other information you feel would be appropriate to give
3. Three references who would be willing to provide letters of recommendation if requested