NAMI-SCC Provider Education Application

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Thank you for your interest in NAMI Santa Cruz's upcoming Provider Education course! This 15-hour course will be held on:

Friday, May 20th 9:30 a.m. - 12:30 p.m.
Friday, May 27th 9:30 a.m. - 4:30 p.m.
Friday, June 3rd 9:30 a.m. - 4:30 p.m.

Due to limited space in our classes, we will not be able to accept all students. Please fill out the form below honestly and to the best of your ability.

First and last name *

Best email to reach you *

Best phone number to reach you *

Job title *

Name of organization *

I work in Santa Cruz County *

Yes

Other:

Are you able to attend all 5 classes in their entirety? (3 consecutive Fridays, May 20th 9:30 a.m. - 12:30 p.m., May 27th and June 3rd 9:30 a.m. - 4:30 p.m.) *

Yes

Other:

I am comfortable using Zoom *

Yes

Other:

Are you interested in receiving CEUs for this course? (LMFT, LCSW, LPCC licenses only) *

Yes

Why are you interested in taking NAMI's Provider Education course? *

How often, and in what capacity, do you work with those with serious mental illness and their families? *

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