TBFVA, Inc.
2020 Registration Flyer
Only 9 training slots are available in any of these trainings.
Total Registration Fee is: $1,300.00 (includes 40 CE's for Social Work, Counselor, & Psychologist; 6 days of
training, & 10 hours of consultation)
Check or Money Order Accepted & Made Payable to: TBFVA, Inc.
You must complete this flyer & return with your 1st half of your payment ($650.00) to reserve you training slot:
TBFVA, Inc.
2429 Gammons Creek Dr.
Maidens, VA 23102
Balance of Fee is due on Day 1 of Training
To receive the entire Registration Information packet, email:
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Schedule: Check the dates you plan to attend. All Times are 8:30am - 4:30pm EST.
_____ Part 1: 7/10, 11, 12/2020 & Part 2: 8/21, 22, 23/2020
_____ Part 1: 9/16, 17, 18/2020 & Part 2: 10/28, 29, 30/2020
_____ Part 1: 11/18, 19, 20/2020 & Part 2: 1/6, 7, 8/2021
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Please PRINT: Be sure everything is readable.
Name:________________________________________ Address:_____________________________________
Email:________________________________ Cell #: ( ___ )________________ City:_______________________
State:______ Zip:________
Type of License:_________________ #:__________________________ State Licensed In:__________________
If Intern, Name of Supervisor:______________________________________
License Type/Number:_____________________________________
(include letter from them stating their role of supervision, their approval to take
training, their license type and number)
Type of CE Certificate: LCSW____ LPC____ Psychologist____
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*NOTE: All of the information below is provided in the Registration Information Packet
I have read & understand that this training is provided virtually on Zoom.us:____(Initial)
I understand that I must have a computer or laptop with internet access:____(Initial)
I have read & understand the consultation requirement:____ (Initial)
I have read & understand the cancellation policy: ____ (Initial)
I have read & understand the recommendation to not participate in this training if pregnant:____(Initial)
I have read & agree to the Notice of Disclosure: Signature:_____________________________________________
