2022 Training for Mental Health Providers–Registration Form Full Name of Person attending the training:* First Last License/Credentials* Occupation* Agency or School* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Name of Person completing this form if different from attendee First Last Email of Person Completing this form--if different from Person Attending the Training. (If you're registering more than one person--please add each person's name and email and which trainings they will be attending to the "Special Accommodations" box. Thank you. Understanding Suicide–What Mental Health Professionals Need to Know About Assessing and Managing Suicide Risk ($100.00) April 22. 2022 (9:00 AM - 4:15 PM) *Understanding Suicide Training* September 23. 2022 (9:00 AM - 4:15 PM) *Understanding Suicide Training* 6 Hour CE Class Suicide Assessment and Treatment. Board Approved for KY LPC, MFT, SW, and Psych *Meets Mandatory Suicide training Requirement* **Currently Provided via Webinar**Domestic Violence for Mental Health Practitioners April 29. 2022 (9:00 AM - 12:15 PM EST) *DV Class* September 9. 2022 (9:00 AM - 12:15 PM EST) *DV Class* 3 Hour CE Class on Domestic Violence. KY Board Approved for KY LPC, MFT, SW, and Psych *Meets Mandatory Domestic Violence training Requirement* **Currently Provided via Webinar**Professional Counseling Law and Ethics April 28. 2022 (9:00 AM - 12:15 PM EST) * LPC Law Class September 8. 2022 (9:00 AM - 12:15 PM EST) * LPC Law Class* 3 Hour CE Class on LPC Law and Ethics. KY Board Approved for KY Counselors *Meets Mandatory LPC Law training Requirement* **Currently Provided via Webinar**Marriage and Family Therapists—Informed Consent for In-Person and Telehealth Services September 2. 2022 (9:00 AM - 12:15 PM EST) * MFT Ethics Class 3 Hour CE Class on Marriage and Family Therapy Ethics. KY Board Approved for Marriage and Family Therapists. *Meets Mandatory MFT Ethics training Requirement* **Currently Provided via Webinar**Social Work Ethics for License Renewal September 24. 2022 (10:00 AM - 1:15 PM EST) *SW Ethics Class* 3 Hour CE Class on KY Social Work Ethics Meets mandatory SW Ethics training requirement Board approved for KY Social Workers **Currently Provided via Webinar**Pediatric Abusive Head Trauma: Understanding Risks, Outcomes, and Prevention September 24. 2022 (8:00 AM - 9:30 PM EST) *Ped. Abusive Head Trauma Class* 1.5 Hour CE Class on Pediatric Abusive Head Trauma Meets mandatory training requirement for KY SWB Board approved for KY Social Workers **Currently Provided via Webinar**Continuing Education needed (you may choose more than one): Counseling Marriage and Family Therapist Psychology Social Work N/A - I'm a Student Other FRYSC If other, please list here* Any special accommodation?Total Cost of Registration: $0.00 May we add you to our mailing list so you can be updated on other upcoming trainings and happenings at Brighter Futures Counseling?* Yes, please! No, thanks. Please read our Cancellation Policy and confirm you've read and understand.*Cancellation Policy I have read and understand the cancellation policy. Name as it Appears on the Credit Card* First Last Credit CardCard Details Cardholder Name NameThis field is for validation purposes and should be left unchanged.