BHS Speaker Registration Form

2nd Annual Behavioral Health Summit: Ethics in Action

Speaker Registration
Thank you for your interest in presenting at our Summit, offering Continuing Education.

Please complete the form below to register as a speaker.
Full Name
Title/Credentials (e.g. PhD, LCSW, MD, etc)
Organization/Institution
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Mailing Address
Website or Professional Profile (if applicable)
Type of License
Date issued

MonthDayYear
Date
License number
Please list any additional credentials and/or certifications
Previous Conferences/Speaking engagements where CEs were provided:
Please list: Subject Matter, Conference/Agency, Year
Please Email a copy of your LICENSE, BIO and most recent CV to info@headsupsavannah.org no later than May 15th, 2026
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Presentation Title
Brief Description of Presentation 200 - 300 words
Learning Objectives (Please list 3-4 specific objectives you will cover in your session):
1
2
3
4
- Continuing Education Credit
- License Type(s) Eligible for CE Credit:
- Social Workers (LCSW, LMSW)
- Psychologists (PhD, PsyD)
- Psychiatrist (MD)
- Marriage & Family Therapists (LMFT)
- Counselors (LPC)
- Other:
Audio/Visual Requirements: Please list any AV equipment or special requirements you may need for your session (e.g.,microphone, projector, screen, etc)
Preferred Session Time (choose one):
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Speaker Agreement & Signature By signing below, you agree to provide an informative and professional presentation that meets the Continuing Education guidelines for the intended audience. You also agree to submit any required documentation, such as learning objectives or course materials, by the deadline.
Date

MonthDayYear
Date
Signature
One free All Day ticket (valued at $160 for up to 6.5 CE's) is included as a thank you from Heads-Up Guidance Services. Please complete the registration form below to collect your free ticket.

Important Dates & Information:

Speaker Submission Deadline: May 15 2026

CE Documentation Submission Deadline: May 15, 2026

Event Date: Friday, July 24th, 2026

For any inquiries, please contact: Text: (912) 800-5701

Email: info@headsupsavannah.org
Attendee Registration Form

Thank you for registering to attend the 1st Annual Behavioral Health Summit:Uniting Minds & Building Resilience! We look forward to having you join us for this important event.

Please complete the form below to confirm your attendance.
Full Name
Preferred Name (if different)
Title (if applicable)
Email Address
example@example.com
Phone Number
Format: (000) 000-0000.
Mailing Address
Continuing Education (CE) Credits (if applicable)Would you like to receive CE credits for attending the summit?

Other
Should be Empty:

2nd Annual Behavioral Health Summit: Ethics in Action

HUGS HEADS-UP GUIDANCE SERVICES

HUGS HEADS-UP GUIDANCE SERVICES