Course Registration Client RegistrationName *Date of Birth *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeEmail Address *PhoneName/Phone Number of Emergency Contact:Do you have a personal history/story with addiction/mental wellness either for yourself or your family (please explain briefly):Do you have any experience/training/education with addiction or mental health recovery?YesNoWhat are your specific goal/goals in attending this course?I understand that this is a certificate of completion course and is not certified by any board or state. It is for educational and professional growth purposesYesNoI understand that this is an interactive course and outcome is commensurate with what I put in: *YesNoBy *Start signing your signature hereYour browser does not support e-Signature field.On *I have read the HIPPA Privacy Statement and agree to it.Send Message