Name*

First Last

Email (enter carefully - this is where notifications and confirmations will be sent for each registered participant)*

Agency/Organization*

Address*

Street Address Address Line 2 City State ZIP Code

Agency Address

Cell Phone (would be used only for emergencies)*

Did you register to attend the IMH Statewide Ethics - Part One training in February?*

What is your category of endorsement, if applicable?*

Please indicate your discipline*

Please indicate your primary practice setting*

How many years have you been doing IMH clinical work?*

What are you most looking forward to getting out of this training? What questions do you have for the presenter?

Base Price

I am registering as a Member ($35) | Non-Member ($50) | Current Student ($20):*

Students will be asked to email a current student ID.

Membership ID*

Are you a Licensed Social Worker (Michigan only) or Licensed Professional Counselor?*

License Number (required for continuing education)*

Total

$0.00

2021.4.16.Statewide.Ethics.Part 2

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