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.
DEADLINE FOR REGISTRATION IS 48HRS BEFORE THE SCHEDULED COURSE
Name *
Please type in all capital letters, this name will appear on your certificate upon completion of the course
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
LCSW
LMFT
LMHC
LCAT
CASAC
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