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DC:0-5 Clinical Training Application
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1.
Name
(Required.)
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2.
Email Address
(Required.)
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3.
Phone Number
(Required.)
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4.
Job Title
(Required.)
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5.
Company/Organization
(Required.)
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6.
Work Address
(Required.)
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7.
Are you currently licensed to diagnose individuals in the state of Tennessee?
(Required.)
Yes
No
Other (please specify)
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8.
Please specify your degree type and licensure.
(Required.)
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9.
How do you plan to use the DC:0-5 Clinical Training in your current role?
(Required.)
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10.
If you are not a clinician or licensed to diagnose in Tennessee, please tell us about how you envision DC:0-5 training supporting your daily work.
(Required.)
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11.
Are you Infant Mental Health Endorsed? If yes, at which category?
(Required.)
No
No, but I am interested in learning more
In process
Yes (Please specify category)
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12.
Applications will be reviewed to ensure participants are a good fit for this training. If your application is accepted you will be notified by email to pay the registration fee in order to complete your registration. By checking the box below, you agree that if your application is accepted, you will:
Attend both training dates
Provide feedback in the form of a post-training survey
Give event organizers a 24-hour notice if unable to attend
(Required.)
I agree
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