Peer to peer training interest form

Clinician Name(Required)

First Last

Clinician Email(Required)

Enter Email Confirm Email

Today's Date

Licensure Type(Required)

Intended Title of Training Presentation

Briefly describe the content on which you'd like to present. Be as concrete and specific as possible.(Required)

List 3 Learning Objectives that persons who attend this presentation will accomplish at the end of the training.

(Example learning objective for a training on Search Engine Optimization for private practitioners: 1. Attendees will identify the foundational concepts of search engine optimization (SEO) and their relationship to a successful search engine ranking for private counseling practice, as well as the corresponding relationship between these concepts and financial profitability.)

Do you have advanced training (e.g., beyond what you learned in graduate school) in this area?(Required)

If yes, please indicate below the date of the training(s), the provider of the training(s), and a brief description of the training. Please also include a website/URL where the organization from which the training emanates.(Required)

If no, please indicate why you are qualified, and what formal and informal training and experiences you have with the intended subject matter. Be as concrete and descript as possible.(Required)

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