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Registration Form: 3-5-7 Model
®
Overview and Applications Webinar Series for
Social Workers, Mental Health Professionals and Individual/Family Therapists
Questions? Contact us at: office@darlahenry.org
* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Email address
*
Your answer
Phone Number (including area code)
*
Your answer
Do you work in a federal or state government funded mental health program?
*
Yes
No
Are you in private practice?
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Yes
No
What are your credentials?
*
Social Worker (MSW, LGSW, LCSW, LMSW, LCSW-C, LISW, LSW)
Marriage and Family Therapist (MA, MFT, LMFT, LCMFT)
Pastoral Counseling (MA, CCPT, CpastC, NCPC, NCCA)
Psychologist: Masters Level (MA, MS, LGPC, LCPC)
Psychologist: Doctorate Level (PhD, PsyD, EdD)
Other:
How did you hear about the webinar series?
*
Website (
www.darlahenry.org
)
Facebook
Linkedin
Flyer was shared with me by a colleague
Other
I understand that participation in this webinar series does not allow me to train others on the 3-5-7 Model® approach.
*
Yes, I understand
Required
I give my permission to be invoiced for the program fee of $500, payable 10 days prior to the first session.
*
Yes, I agree
Required
Comments and/or questions
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