2019 North Central Indiana Mental Health Summit
Please complete this form and provide payment to finalize your conference registration. The 2019 North Central Indiana Mental Health Summit will occur on Saturday, November 16, 2019 from 9:00 AM to 4:00 PM. This year's theme is "Resilience", and we are delighted to bring you sessions from presenters from wide-ranging backgrounds and expertise. Expect to learn new ideas and strategies you can use immediately in your life and work. A continental breakfast and buffet lunch will be served, along with beverages all day. We welcome you to join us for a day of networking, reflection, and discovery!
Please type your name: *
Your answer
Type your phone number here: *
Your answer
Add your email here *
Your answer
Enter the billing address used with your credit card payment *
Your answer
If you prefer NOT to pay by paypal, please write in your preferred payment method here so we can contact you about payment:
Your answer
**If your payment will be for more than one attendee and/or the credit card information is not in your name, please list attendees in the Comment Box on the Payment Form (if available) and also here:
Your answer
Enter your zip code here: *
Your answer
Type your profession here. Examples include pharmacist, physician, mental health counselor, psychologist, veterinarian, social worker, etc. *
Your answer
Are you currently a student in your profession? *
Please indicate your preference for a morning breakout session by ranking the choices from 1-3. *
1
2
3
A. Out in the World: Working with LGBTQ clients and consumers. Jim Ryan, Certified Prevention Specialist, brings experience from publishing, social justice advocacy, community service, and corporate training to this workshop focused on how the experience of minority populations can uncover resiliency strategies and skills.
B. Provider CPR: Preventing Burnout. Linda Adeniyi, Clinical Team Lead and Therapist with The Julian Center in Indianapolis, brings her experience working with survivors of sexual and domestic violence to bear in this workshop discussing self-care for providers.
C. Understanding the Tyranny of the Moment: Health Consequences of Poverty. Marie Wiese, Circles Indy Coordinator, and her associates will lead a breakout session discussing poverty, fortitude, and transitions. Circles Indy is a national relationship-based movement to help communities become educated about the causes of poverty and the barriers that keep people in poverty. Circles directly helps individuals and families living in poverty to achieve self-sufficiency.
We would be happy to accommodate your Americans with Disabilities Act (ADA) needs. Please specify below how we can be helpful.
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy