Registration (step 2 of 2)

Please fill out the form below and we will contact you shortly.

Name
First Last
Email
Enter Email Confirm Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
License Type and Number (for example: PSY 12345)
Agreement
Please check the boxes below:
Requirements for Participation*
I have the educational training, qualifications, and professional credentials to practice as a mental health professional or counsellor in the area where I live or I am in a formal training program or supervised internship to become a mental health professional. Note: Local trainers can, at their discretion, add specificity to or verify these credentials.
- Agreed
Confidentiality Agreement a*
I agree to keep confidential the personal identifying information of case material shared in the training.
- Agreed
Confidentiality Agreement b*
I agree to not record any part of this training in any format (audio, video, or visual). Personal written notes of non-confidential material are permitted.
- Agreed