Conference Registration Credit Card This online registration is for attendance to the full-day Zoom conference featuring both speakers. No CE Credits will be awarded for partial attendance. Name* First Last Licensed Degree*Licensed DegreePh.D.Psy.D.LMFTLCSWStudentTraineeReg. InternOtherAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Registration Type*$125.00 - Students, Trainees & Interns$175.00 - Licensed and OtherCredit Type*6.0 CE Credits LMFT/LCSW6.0 CE Credits PsychologyNo CreditTotal $0.00 Payment Method*Credit CardCheckCredit Card* DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20222023202420252026202720282029203020312032203320342035203620372038203920402041 Expiration Date Security Code Cardholder Name
