2023 Kentucky Mandated Trainings–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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin 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) Friday January 20, 2023 (9:00 AM - 4:00 PM) *Understanding Suicide Training* ZOOM *$100.00 Thursday April 27, 2023 (9:00 AM - 4:00 PM) *Understanding Suicide Training* ZOOM *$100.00 Friday September 29, 2023 (9:00 AM - 4:00 PM) *Understanding Suicide Training* ZOOM *$100.00 6 Hour CE Class Suicide Assessment and Treatment. Board Approved for KY LPC, MFT, SW, and Psych *Meets Mandatory Suicide training Requirement* **Provided Live via Zoom**Domestic Violence for Mental Health Professionals Thursday January 19, 2023 (9:00 AM - 12:00 PM) *Domestic Violence* ZOOM *$50.00 Thursday April 20, 2023 (9:00 AM - 12:00 PM) *Domestic Violence* ZOOM *$50.00 Thursday September 21, 2023 (9:00 AM - 12:00 PM) *Domestic Violence* ZOOM *$50.00 3 Hour CE Class Domestic Violence Board Approved for KY LPC, MFT, SW, and Psych *Meets Mandatory Domestic Violence training Requirement* **Provided Live via Zoom**Professional Counseling Law and Ethics Friday April 21, 2023 (9:00 PM - 12:00 PM) *LPC Law* ZOOM *$50.00 Friday September 22, 2023 (9:00 PM - 12:00 PM) *LPC Law* ZOOM *$50.00 3 Hour CE Professional Counseling Law and Ethics Board Approved for KY LPC *Meets Mandatory LPC Law training Requirement* **Provided Live via Zoom**Marriage and Family Therapist Ethics with 2 hour Telehealth Renewal Wednesday April 19, 2023 (9:00 PM - 12:00 PM) *MFT Ethics* ZOOM *$50.00 Friday September 1, 2023 (9:00 PM - 12:00 PM) *MFT Ethics* ZOOM *$50.00 3 Hour CE MFT Ethics Board Approved for KY MFT *Meets Mandatory MFT Ethics training and 2 hour Telehealth training Requirement* **Provided Live via Zoom**Social Work Ethics for License Renewal Friday April 21. 2023 (10:00 AM - 1:15 PM EST) *SW Ethics Class* ZOOM *$50.00 Friday September 22. 2023 (10:00 AM - 1:15 PM EST) *SW Ethics Class* ZOOM *$50.00 3 Hour CE Class on KY Social Work Ethics Meets mandatory SW Ethics training requirement Board approved for KY Social Workers **Provided Live via Zoom**Pediatric Abusive Head Trauma: Understanding Risks, Outcomes, and Prevention Thursday January 19, 2023 (1:30 PM - 3:00 PM EST) *Ped. Abusive Head Trauma Class* ZOOM *$50.00 Friday April 21, 2023 (8:00 AM - 9:30 AM EST) *Ped. Abusive Head Trauma Class* ZOOM *$50.00 Friday September 22, 2023 (8:00 AM - 9:30 AM EST) *Ped. Abusive Head Trauma Class* ZOOM *$50.00 1.5 Hour CE Class on Pediatric Abusive Head Trauma Meets mandatory training requirement for KY SWB Board approved for KY Social Workers **Provided Live via Zoom**Continuing Education needed (you may choose more than one): Counseling Marriage and Family Therapist Psychology Social Work N/A - I'm a Student Other If other, please list here* Any special accommodations or anything else you would like us to know?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.