Digital Signature (please your type full name below to attest that you have completed the training)

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* 1. Digital Signature (please your type full name below to attest that you have completed the training)

What is your profession? (example: LMFT, LP, etc.)

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* 2. What is your profession? (example: LMFT, LP, etc.)

What is your License Number, and what state or province are you licensed in?

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* 3. What is your License Number, and what state or province are you licensed in?

What is your email address?

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* 4. What is your email address?

What is your street address?

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* 5. What is your street address?

What is your phone number?

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* 6. What is your phone number?

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