Traumatic Brain Injury & Substance Use Disorder: Intimate Partner Violence
Certificate of Continuing Education/Attendance
Fill out the form and submit payment to receive certificate.
Name
*
First Name
Last Name
Provider Type
*
Rehabilitation Counselor
Social Work
General Attendance
NAADAC
CHES
Iowa Board of Certification
Missouri Credentialing Board
Kansas Behavioral Sciences Regulatory Board
Nebraska (accepted for CE for licensed alcohol and drug counselors in NE)
License Number (if applicable)
Organization/Agency
*
Phone Number
*
-
Area Code
Phone Number
E-mail Address
*
Confirmation Email
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Webinar Evaluation
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
1. The information is applicable to my profession.
2. The presenter(s) were knowledgeable about the subject matter.
3.
I learned a great deal from this webinar.
4. Overall, this presentation met my needs.
5. How much did you learn as a result of this CE program?
*
1
2
3
4
5
Very Little
Great Deal
1 is Very Little, 5 is Great Deal
6. How useful was the content of this CE program for your practice or other professional development?
*
1
2
3
4
5
Not Useful
Extremely Useful
1 is Not Useful, 5 is Extremely Useful
Additional Comments:
7. 1 in 3 women experience domestic violence.
*
True
False
8. Substance use and domestic violence are not highly correlated.
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True
False
Date of Submission
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