Home Study Registration 3

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 (please describe):

Rate:*

Regular Rate $25.00 USD
Agency/Group Rate $150.00 USD
Equity Rate (self-selected)

Agency/Group Rate: This registration option is for groups of clinicians working in community mental health settings or group practices.

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 $5.00):*

Price: $5.00

Agency/Group Practice:*

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