CEN Therapist Newsletter & Referral List Form
TO SIGN UP FOR THE CHILDHOOD EMOTIONAL NEGLECT NEWSLETTER ONLY:

If you are a therapist, certified coach, or other mental health care professional who would like to be added to my newsletter to stay updated on my writings and CE trainings for therapists but do not wish to be or do not qualify to be listed as a CEN therapist to receive referrals, just fill out your name and credentials plus your email. You can leave the other fields blank.

**To apply to be listed on my Find a CEN Therapist Page, you must complete all of the below:**

1. Be licensed/certified.
2. Read both of my books, Running On Empty: Overcome Your Childhood Emotional Neglect and Running On Empty No More: Transform Your Relationships.
3. Take my 2 CE online training, "Treating Childhood Emotional Neglect Overview" AND/OR either of my 12 CE online CEU trainings, "Fuel UP For Life" or "Fuel Up For Life For Therapists." Learn more about the trainings under the Programs tab of www.emotionalneglect.com.
4. Fill out this form completely. **BE SURE TO INCLUDE YOUR TOWN/CITY AND STATE/PROVINCE OR WE WILL NOT BE ABLE TO LIST YOU.

To update your CEN Therapist Listing in the future, please select "Yes" to the first question.

THANK YOU! I look forward to staying connected with you!

Warmly,
Jonice
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Are you updating your CEN Therapist Listing? (If this is your first time submitting please select "No.")
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Please fill out your full name including credentials *
Please give your contact email. *
Are you a licensed/certified psychotherapist or coach?
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What is the town *AND* state or province *AND* country of your practice? **Include your town and state/province or we will not be able to list you.
Have you read the books Running on Empty and Running On Empty No More?
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Have you taken either the 2 CE online training, "Treating Childhood Emotional Neglect Overview" AND/OR either of my 12 CE online CEU trainings, "Fuel UP For Life" or "Fuel Up For Life For Therapists?" You must take one of these trainings to qualify for the list.
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Please List Your Specialties
Are you willing to do online video therapy?
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Please give your phone number.
Please give your website address if you have one.
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