Clinical Mentorships

Program Registration Form

 

This is a two step registration process.
Step 1 is filling out the informational request form below.
Step 2 is clicking Continue to complete the payment process.
All applicants must submit a $250 application/administrative fee. This fee will be refunded if you are not accepted in the Intensive Mentorship program at this time.

ONLINE REGISTRATION - STEP 1
* denotes required fields

LEVEL 2: Hands-On Advanced Treatment
I would like to attend Intensive Mentorship - Level 2 on the following dates (select one) *

February 20 - 24

March 26 - 30

LEVEL 2:
If my first choice is not available, an alternate date I would attend is (select one)*:

February 20 -24

March 26 -30

2012
Prefix: Mr.   Mrs.   Ms.
First Name*:
Last Name*:
Address*:
City*:
State/Province:   Zip/Postal Code:
Country:
This is my: Business Address   Home Address
Home Phone*:
Mobile Phone:
Work Phone:
Email*:
Job Title / Profession*:
Company / Organization:
What is your work setting?* (ie: School, Clinic, Home-Based, Private Practice, Hospital, other)
What are your goals for Level 2 mentorship training?
1*.
2*.
3.
What areas do you consider your strengths relative to the treatment process?*
What are your specific areas for development relative to the treatment process?*
Attach copy of your CV and updated continuing education record (date, program and instructor name)*
(Word or PDF only please)

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