Koumidou Center Registration Form
You will receive an email after submitting this form with further information if you prefer to pay by check.
If registering less than 10 days prior to the course date, payment has to be submitted by credit card only.
Name *
Please type in all capital letters, this name will appear on your certificate upon completion of the course
Your answer
Credentials
These will appear on your certificate upon completion of the course - State Board Requirement
Please indicate your credential(s) *
Required
License Number
Enter the License Number(s) for the credentials indicated above
License Number(s) will appear on your certificate upon completion of the course - State Board Requirement
LMSW
Your answer
LCSW
Your answer
LMFT
Your answer
LMHC
Your answer
LCAT
Your answer
CASAC
Your answer
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