Complete for CE Processing

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* 1. Name:

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* 2. Agency/Company

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* 3. Date of Birth:

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* 4. Mailing Address:

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* 5. Phone Number:

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* 6. Email Address:

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* 7. License Type (e.g., LPC, LMHC, LCSW, LMFT)

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* 8. State Licensed:

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* 9. License #:

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* 10. Are you a National Certified Counselor (NCC) as certified by the National Board for Certified Counselors (NBCC)?

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* 11. Date Training Completed:

Date
Please rate the following items on a scale from 1 to 5.

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* 12. Speaker's presentation style and ability to maintain interest.

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* 13. Speaker's knowledge and expertise of the subject.

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* 14. Program topic and objectives were clearly stated and met.

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* 15. Program content and structure met stated expectations.

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* 16. Usefulness of material to my professional practice

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* 17. Opportunity for interactions and exercise

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* 18. Quality of supplied course materials

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* 19. Length of presentation and use of time was effectively managed

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* 20. Impression of the overall value of the training session

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* 21. Quality of training promotional materials

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* 22. What did you like the most about the training?

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* 23. What did you like the least?

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* 24. What other training topics would you like to see SMHCA provide?

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* 25. Would you like to receive CEs (continuing education credit) for this training program?

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* 26. Other Feedback/Comments:

T