CE and Leadership Cohort Inquiry Form
Complete form below to request cohort services with Your Therapy Doctor.
Company Information
Organization/Business Name
EIN/TIN Number
Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
General Details of Services/Goods for the company
Contact Information
Please provide information regarding your request for training.
Point of Contact
First Name
Last Name
Phone Number (Day)
Format: (000) 000-0000.
Phone Number (Evening)
Format: (000) 000-0000.
E-mail
example@example.com
Training Request Information
Please provide information regarding your request for training.
Potential Date for Training
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Audience Attending the training
Please provide the professional background of attendees (Students, Military, Senior Leadership, Interns, etc.)
Number of Attendees
Format of Training
Please Select
In-Person
Online
Pre-Recorded
Hybrid
Type of Training
Continuing Education (CE)
Leadership
Would you like a private cohort session for your organization?
Yes
No
Credit Hours
Certified Professional Development (CPD)
Approved Continuing Education Provider (ACEP)
Not Applicable
How did you hear about the Continuing Education courses?
Social Media (Facebook, Instagram, Linked In)
Your Therapy Doctor or Dr. Pauline Belton Websites
Other
Name of the course(s) for the training
*
Boundaries, Balance & Emotional Energy™
Creating Psychological Safety at Work™
Emotional Intelligence for Teams™
Leading Through Change & Uncertainty™
Navigating Stress, Anxiety & Burnout™
Navigating Stress in the Workplace™
Power & Presence: The EQ Advantage™
Reset to Rise™
Restorative Communication & Conflict Reset™
Self-Leadership: Emotional Mastery from the Inside Out™
The H.E.A.R.T. of Resilient Leadership™
Your Leadership, Your Culture™
Customized
Please verify that you are human
*
Send Application
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