A Five-Week (15 CEU) Training Seminar 2018 at Elliott Counseling Group

* 1. What is your first name?

* 2. What is your last name?

* 3. What is your date of birth?

* 4. What is your street address? Please include city, state, zip.

* 5. At what email address would you like to be contacted?

* 6. What is your phone number? We will contact you to confirm your spot in the seminar.

* 7. Where is your current place of employment or organization?

* 8. What is your profession & Licensure?

* 9. Are you wanting to receive 15 CEUs for this "Understanding and Treating Trauma" Seminar?

* 10. The cost of the group is $300. The cost for not for profits employees & ECG staff is $250. Would you like to mail the payment in or call us to give us your credit card information? If you would like to mail in, make all checks payable to: Kevin Elliott Counseling. If you would like to call in with a payment, please call our offices at 217-398-9066. Payment is due in full.

* 11. How did you hear about this seminar?