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