* 1. Contact Info

* 2. Are you registering as an individual or as a member of a group of 3 or more from the same agency?

* 3. Do you currently work with domestic violence victims/survivors?

* 4. If yes, what agency do you work for?

* 5. We are considering applying for CEUs for those of you who are licensed practitioners if there is enough interest.  If you would like to receive, for an additional $35 fee, approximately 38 CEUs for completing this class, please indicate for which license: