REGISTRATION FORM - Print, Fill Out and Mail

SPECIAL DISCOUNTS IF YOU REGISTER NOW FOR MORE THAN 1 WORKSHOP:

1 Workshop = $119                         3 or 4 Workshops = $108/each
2 Workshops = $114/each                      5 or more Workshops = $103/each

Workshop discounts must be pre-paid and can be used by one person (not multiple people)
Add $10/per workshop for Psychologist CE Credit

NAME ___________________________________

POSITION ___________________________ORGANIZATION _____________________________

Please indicate where you prefer to receive mailings: HOME ____ WORK _____

ADDRESS _______________________________________CITY _________________________

STATE ______ZIP ________ E-MAIL ADDRESS ___________________________________

WORK PHONE ___________________ HOME PHONE _________________________

I want CE credits for:
___ Social Worker CE - ___LICSW ___LCSW ___LSW - Lic # _________________
___ MH Counselor CE - Lic # _________________      ___OT Contact Hours
___Natl Cert Counselor CE    ___Nurse Contact Hours    ___Marriage & Family CE   
___Substance Abuse or LADC CE    ___Psychologist CE ___Educator Certificate   

Dates Location Workshops Fee
Friday, December 3, 2010 Foxborough, MA Serving Those Who Served:  Best Practices for Supporting Veterans & Their Families $119
Friday, December 10, 2010 Billerica, MA A Piece-by-Piece Approach to Solving the Autism Puzzle $119
Thursday, December 16, 2010 Springfield, MA Creating Safer Spaces for Lesbian, Gay, Bisexual & Transgender Youth & Families $119
Friday, December 17, 2010 Billerica, MA The Ups & Downs of Helping Youth & Families in Foster Care Settings $119
Thursday, January 13, 2011 Billerica, MA The Impact of Ethnic & Cultural Background on Mental Health & Psychopharmacology $119
Thursday, January 20, 2011 Foxborough, MA Treating Adult Depression: Practical Strategies for Lasting Emotional Relief $119
Thursday, March 3, 2011 Foxborough, MA Hurry Up & Relax: Mind/Body Medicine for Today's Stressed World $119
Friday, March 4, 2011 Billerica, MA Nothing Ventured, Nothing Gained: Managing Therapeutic Risk-Taking $119
Thursday, March 10, 2011  RESCHEDULED FROM FEBRUARY 2, 2011 Springfield, MA Life Coaching Interventions for Youth: Evidence-Based Strategies $119
Friday, March 11, 2011 Billerica, MA Mental Health Treatment of the Developmentally Delayed Child: Best Practices $119
Thursday, March 24, 2011 Billerica, MA Grief & Loss: A Family Affair $119
Thursday, March 31, 2011 Springfield, MA Anxiety in America: Practical Strategies for Treating Anxiety & Fear in Adults $119
Thursday, April 7, 2011 Billerica, MA Best Practices in Adoption: Guiding Youth & Families towards Permanency $119
Thursday, April 14, 2011 Billerica, MA Attention Deficit/Hyperactivity Disorder (ADHD) Across the Lifespan $119
Friday, April 15, 2011  RESCHEDULED FROM JANUARY 21, 2011 Billerica, MA Dangerous Sex Offenders:  Strategies for Mental Health Professionals $119
Friday, April 29, 2011 Foxborough, MA Taming the Emotional Dragon:  Reaching Youth with Reactive Attachment Disorder $119
Thursday, May 12, 2011 Billerica, MA Groups to the Rescue:  Maximizing Impact with Challenging Youth $119
Friday, May 13, 2011 Springfield, MA Who Really Wants to Change? Stage-Wise Treatment for Co-Occurring Disorders $119
Thursday, May 26, 2011 Billerica, MA Compassion Fatigue & Resiliency: Replenishing Your Spirit $119
Thursday, June 2, 2011 Foxborough, MA Understanding & Confronting Ethical Challenges:  Improving Practice & Care $119
Thursday, June 9, 2011 Billerica, MA Treating PTSD in Adults Impacted by Sexual Trauma $119
Friday June 10, 2011  RESCHEDULED FROM FEBRUARY 3, 2011 Billerica, MA Treating Complex Trauma in Children & Families $119
Thursday, June 16, 2011 Springfield, MA Navigating the Storms and the System:  Coaching Transitional Age Youth & Their Families $119
Thursday, July 21, 2011 Billerica, MA Impulsive and Self-Harming Adolescents:  A Dialectical Behavior Approach $119
Thursday, July 28, 2011 Springfield, MA Tackling Bullying in Schools and Beyond:  Working to Make a Real Difference $119
Thursday, August 4, 2011 Foxborough, MA No Such Thing As a Bad Kid: Reshaping the Lives of At-Risk Youth - Part II $119
Thursday, August 11, 2011 Billerica, MA Treating Children & Families: Avoiding Ethical Pitfalls $119
Total number of Workshops ____at $ ____each = TOTAL:$______
Psychologists - - Add $10 CE Fee per Workshop = TOTAL: $______
TOTAL FEE: $______
All Major Credit Cards Accepted
All major credit cards accepted

Please charge my: MC__ VISA__ DISCOVER__ AMEX__

CARD #________________________ EXP. DATE_________

SECURITY CODE #________ SIGNATURE____________________________

Mail with your non-refundable check to the address below or fax to: 978-535-1557.

Community Program Innovations, Inc.
471 Broadway, Lynnfield, MA 01940.

Payment must accompany registration form.