CEN Therapist Newsletter & Referral List Form

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TO SIGN UP FOR THE CHILDHOOD EMOTIONAL NEGLECT NEWSLETTER ONLY:

If you are a therapist, certified coach, or other mental health care professional who would like to be added to my newsletter to stay updated on my writings and CE trainings for therapists but do not wish to be or do not qualify to be listed as a CEN therapist to receive referrals, just fill out your name and credentials plus your email. You can leave the other fields blank.

**TO APPLY TO BE LISTED ON MY FIND A CEN THERAPIST PAGE, PLEASE COMPLETE ALL OF THE BELOW:

1. Be licensed/certified.
2. Read both of my books, Running On Empty: Overcome Your Childhood Emotional Neglect and Running On Empty No More: Transform Your Relationships.
3. Take my 2 CE online training, "Treating Childhood Emotional Neglect Overview", or either of my 12 CE online CEU trainings, "Fuel UP For Life" or "Fuel Up For Life For Therapists," or attend an in-person retreat. Learn more about the trainings under the Programs tab of www.emotionalneglect.com.
4. Fill out this form completely. **BE SURE TO INCLUDE YOUR TOWN/CITY AND STATE/PROVINCE OR WE WILL NOT BE ABLE TO LIST YOU.

**TO UPDATE YOUR CEN THERAPIST LISTING, PLEASE FOLLOW BELOW INSTRUCTIONS:
1. E-mail support@drjonicewebb.com
2. Copy and paste your full listing as it is currently listed, and then add a note to each section that you want updated with new information.

THANK YOU! I look forward to staying connected with you!

Warmly,
Jonice

Please fill out your full name including credentials *

Please give your contact email. *

Are you a licensed/certified psychotherapist or coach?

Yes

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What is the town *AND* state or province *AND* country of your practice? **Include your town and state/province or we will not be able to list you.

Have you read the books Running on Empty and Running On Empty No More?

Yes

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Have you taken either the 2 CE online training, "Treating Childhood Emotional Neglect Overview" AND/OR either of my 12 CE online CEU trainings, "Fuel UP For Life" or "Fuel Up For Life For Therapists?" You must take one of these trainings to qualify for the list.

2 CE Treating Childhood Emotional Neglect

12 CE online Fuel Up for Life or Fuel Up For Life For Therapists

In-Person Retreat and Training

No, I have not taken either course.

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Please List Your Specialties

Are you willing to do online video therapy?

Yes

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Please give your phone number.

Please give your website address if you have one.

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