TBFVA, Inc.

2021 Registration Flyer

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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)

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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 

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Balance of Fee is due on Day 1 of Training

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To receive the entire Registration Information packet, email: tbf2inc@gmail.com

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Schedule: Check the dates you plan to attend. All Times are 8:30am - 4:30pm EST.

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____ Part 1:  8/27, 28, 29/2021       &     Part 2:    10/1, 2, 3/2021

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____ Part 1:  9/22, 23, 24/2021       &     Part 2:    10/27, 28, 29/2021

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____ Part 1:  11/10, 11, 12/2021       &     Part 2:    1/5, 6, 7/2022

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Please PRINT: Be sure everything is readable.

 

Name:________________________________________           Address:_____________________________________

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Email:________________________________ Cell #: (   ___  )________________   City:_______________________

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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____   

 

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*NOTE: All of the information below is provided in the Registration Information Packet

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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:_____________________________________________