Name *

First Name

Last Name

Phone

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Checkbox *

I am interested in joining as a Presenter (show clinical videotape twice during the 10-session life of the group)

I am interested in joining as a Learner (not required to show clinical videotape)

I might be available for a Consultation Group that meets select Mondays from noon-2pm EST, starting later this Fall.

I might be available for a Consultation Group that meets select Fridays from 4-6pm EST, starting later this Fall