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

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* 1. What is your first name?

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* 2. What is your last name?

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* 3. What is your date of birth?

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

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

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

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

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* 8. What is your profession & Licensure?

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

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* 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.

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* 11. How did you hear about this seminar?

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