Centers of Excellence 2015 Conference - Innovative Approaches to Prevention:

Enhancing Mental Health

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* 1. PERSONAL INFORMATION

First Name:

Last Name:

Job Title:

Work Location / Agency:

Email Address:

Phone Number:

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* 2. Continuing Education Credits have been requested for Social Work, Nursing, Psychology, OT and LMHC. (Approval is still pending.) Please select one of the following if requesting CEUs:

Social Work

LMHC

OT

Nursing

Psychology

2nd Discipline if requesting more than one.

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* 3. Do you need a special accommodation, including dietary, to fully participate in this conference? If yes, please specify in the box below.

Yes

No

Please Specify:

If you have additional questions please email bobbi.spofford@massmail.state.ma.us.