Acceptance and Commitment Therapy Intermediate Level Certificate Program

UB School of Social Work Office of Continuing Education

Acceptance and Commitment Therapy Intermediate Level Certificate Program (use this title link to details on the program)

Please complete all questions. You will be contacted once a decision on your acceptance is made. You register and pay after acceptance.

Cost: $600 early bird discount by 8/15/19; $650 after 8/15/19. No additional discounts or discount certificates may be applied to the early bird price.

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* 1. Please enter your contact information.

First & Last Name

Full Agency Name

Complete Home Address

City/Town

State/Province

ZIP/Postal Code

Work Phone Number

Preferred Email Address

Cell Phone Number

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* 2. What is your current clinical licensure status?

LMSW

LCSW

LCSW-R

LMHC

LMFT

LCAT

Psychologist

Other (please specify) license type or degree if not licensed

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* 3. Are you currently working with clients in individual and/or group mental health or substance use counseling?

Yes

No (You are not eligible if the answer is 'no'.)

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* 4. Are you available to attend all four full days in 2019: Sept. 6, Oct. 4, Nov. 1, & Dec. 4?

Yes

No (You are not eligible if the answer is 'no'.)

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* 5. Prior ACT training is required.
Select the correct answer from the 3 choices

Instructions:
1. If you previously took Seaghan Coleman's two-day ACT course with us, you will be immediately accepted & sent a registration/payment form. We can verify this in our training records.
2. If you obtained ACT training or engaged in extensive independent ACT study, your application is subject to review for an acceptance decision. Please specify in the text box below the details of your ACT training. Provide dates if applicable. You will be contacted if there are questions. An acceptance decision will be promptly issued and if accepted, a registration/payment form will be sent

Yes, I previously took the two-day ACT course with Seaghan Coleman.

I am registered for the June 18 & 19, 2019 two-day ACT course with Seaghan Coleman.

I have other ACT training or ACT self-study that I have explained in the section below.

Explain your other ACT training if you did not take the two-day ACT course with Seaghan Coleman. If it was a formal live or online training, specify the title, date, and number of training hours. If you independently have been reading and studying ACT on your own, with a group of colleagues or other systems, please explain that.

Thank you! We will acknowledge receipt of your application by email. Acceptance decisions will be made in accordance with the information in question #4. For those accepted, instructions will be provided on how to pay by check, purchase order, or credit card.
All program details are on the website.