Home Study Registration 1

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
AASECT Certified
Student or Unlicensed Professional
Other (please describe):

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License Number:

Rate:*

Regular Rate $35.00 USD
Agency Clinician/Student Rate $25.00 USD
Equity Rate $25.00 USD

*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.

Agency/School:*

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Additional Fee for CEs:

CEs $20.00 USD
No CEs $0.00 USD

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Coupon

Payment Method:*

Credit Card or PayPal

How did you hear about this workshop?*

CFINE Email
CFINE Website
Word of Mouth
Agency Director
Other (please describe):

Would you like to join our mailing list?*

Yes, please!
No, thanks

Total

$0.00