EFT Event Registration 4

Workshop Name:*

Name:*

First Last

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone:*

Email:*

License Type:*

LICSW
Lic. Psychologist
LMFT
LMHC
Student or Unlicensed Professional
Other

Other:*

Early Bird applies until:*

Rate:*

Regular Rate Full $175.00 USD
Student/Agency Clinician Rate Full $125.00 USD
Equity Rate (self-selected)

*Agency Clinician/Student Rate: We offer this discounted rate to enable students and clinicians working in community mental health settings on a full-time basis to be able to participate. Group practices are not eligible.

*Equity Rate: This registration option is for participants with historical/institutional barriers to access. Please choose equity pricing only if you are a member of one or more historically marginalized communities.

Equity Rate (select a multiple of $10.00):*

Price: $10.00 Quantity:

Agency/School:*

Additional Rate for CEs:*

CEs $20.00 USD
No CEs $0.00 USD

Coupon:

Payment Method:*

Credit Card or PayPal

How did you hear about this workshop?*

CFINE Email
CFINE Website
Word of Mouth
Other

Other (please describe):*

Join our mailing list to learn about upcoming programs and discounts:*

Yes, please!
No, thanks

Total:

$0.00