Washington Association for Infant Mental Health · DC05 for Clinicians_Online

DC: 0-5 for Clinicians

December 8 -10, 9am-12pm

Online

Due to a generous grant, we are able to reduce the fees for this December 2020 training from the original registration fee of $450.

$350 (no CEUs) | $395 (with CEU's)

IF YOU ARE AN ORGANIZATION AND WOULD LIKE TO REGISTER MULTIPLE STAFF MEMBERS AND RECEIVE ONE GROUP INVOICE, PLEASE CONTACT US AT TRAINING@WA-AIMH.ORG (DO NOT COMPLETE THIS FORM).

Are you completing this registration form for yourself or someone else (e.g., a staff member)?

Myself

Someone else

Name

First Name

Last Name

What is your infant/early childhood mental health role?

Check all that apply.

Advocate

Child Welfare Staff Member

Community Health Worker

Community Organizer

Early Childhood Educator/Childcare Provider

Educator

Home Visitor

Management/Administration

Mental Health Provider

Nurse

Occupational Therapist

Parent Educator

Physical Therapist

Physician

Researcher

Social Worker

Special Educator

Speech and Language Therapist

Student

Other

Type of email?

Personal

Work

Organization/Employer

Program model, if applicable (e.g., home visiting model)

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County of residence

Professional role

This training was designed by ZERO TO THREE for advanced practitioners, including mental health clinicians, psychiatrists, pediatricians, nurse practitioners, and early interventions whose work with infants, young children and their families involves expert assessment, diagnosis, and case formulation. Do you hold one of these job roles and/or conduct assessment, diagnosis and case formulation in your work with families?

Yes

Required Manual: DC: 0-5

Would you like to add the purchase of the DC: 0-5 manual to your registration?

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood: DC: 0-5 is required for this training--we will be using it heavily throughout each day. You may use your own copy, or we can purchase one (paperback) for you and mail it to you prior to the training (must register 10 days prior to the training).

Yes ($50)

No, I will use my own copy

Mailing address (if different than the one above)

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Would you like to receive CEUs?

CEUs will be available for Licensed Social Workers, Mental Health Counselors, and Marriage and Family Therapists (pending approval). The CEU fee is $45 for 8 hours.

Yes

Payment

You must click "submit" at the bottom of the page to complete your registration and proceed to payment.

Registration Amount

$350 - Registration (no CEUs or manual)

$395 - Registration & CEUs

$400 - Registration & manual

$445 - Registration, CEUs, & manual

Training Demographics Survey

Optional: The data collected below allows us to better understand our training participants and can help us communicate our impact to scholarship funders. Data is only reported for groups as a whole--your individual information will be kept confidential. By filling out the survey below, you are acknowledging that the information you provide can be included in WA-AIMH summaries and reports. Please provide any information that you are comfortable sharing. WHEN YOU ARE FINISHED, PLEASE CLICK 'SUBMIT' AT THE BOTTOM TO COMPLETE YOUR REGISTRATION.

Highest degree earned

High School/GED

CDA

Associates

Bachelors

Masters

Doctorate

Medical or Law

Field Employed

Please describe.

Field Employed (other)

Years worked with infants, young children, and families

Less than 2 years

2 - 5 years

5 - 10 years

10+ years

Individual annual income

<$10,000

$10,000-$30,000

$30,000-$50,000

$50,000-$70,000

$70,000-$90,000

$90,000+

Do you directly support families on a weekly basis?

Yes

Do you supervise staff who directly support families?

Yes

Ethnic background (self-describe)

Please describe.

Please describe your gender (if desired).

Do you live in the community you serve?

Yes

Please click "submit" to complete your registration below.

We will contact you to confirm your registration.