Registration for ACTS (Adolescent and Youth Clinical Training for Suicide Prevention): Screening and Management in Outpatient Settings

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Registration for ACTS (Adolescent and Youth Clinical Training for Suicide Prevention): Screening and Management in Outpatient Settings - January 30th, 2024

Please complete this form to register for the upcoming Adolescent and Youth Clinical Training for Suicide Prevention (ACTS) on January 30th, 2024 at Youth Consultation Service, 60 Evergreen Place, 10th Floor, East Orange, NJ 07018.

To be accepted into the ACTS training, you must be a licensed professional who treats youth under the age of 18. Please note that your registration indicates your agreement to participate in the course post-evaluation and required 3 & 6 month follow ups evaluations. Please agree to complete all of the pre and post tests to be eligible to receive CEU credits below. There is a limited number of spots for this training. After completing this form, you will be be sent an email confirming your registration for the workshop. Prior to the training you will also receive a reminder email with time and location information.

Email *

First Name *

Last Name *

Business Name

Mailing Address *

Confirm email address *

Phone # *

Gender *

Male

Female

Non-Binary

Two Spirit

Other:

Personal Pronouns *

Ethnicity *

African American

Asian American

Hispanic/Latino

Native American

Pacific Islander

White/ Non-Hispanic

Prefer not to answer

Other:

Required

Education Level *

High School Graduate

Associate Degree

Bachelor's Degree

Master's Degree

Professional Degree

Doctorate Degree

Prefer not to say

Other:

Required

Employer *

Professional Designations (PsyD, LCSW, etc) *

How long have you been in practice? *

Do you treat patients under the age of 18? *

Yes

Age *

19-24

25-34

35-44

45-54

55-64

65+

Prefer not to say

How did you hear about this training? *

My Employer

Social Media

My Professional Organization

Received an Invitation Flyer by Email

Department of Children and Families

NJAMHAA

Other:

I agree to attend this training in-person on January 30th, 2024 at Youth Consultation Service. *

I agree

Required

I agree to complete the pre-test and post-test before and after training completion. *

I agree

Required

I agree to be contacted for a 3 & 6 month follow up. *

I agree

Required

I agree to attend the entire training to receive full CEU credits. *

I agree

Required

Is there anything else we should know?

Submit

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