Name of Workshop:

Name of Speaker:

Date of Workshop:

The Center for Behavioral Health now offers Continuing Education Credits (CEU) for attending Breakfast Learning Series (BLS) presentations (as approved by the Indiana Social Worker, Marriage & Family Therapist, and Mental Health Counselor Board). Attendees are encouraged to ask their individual licensing organizations if continuing education credits authorized by this board are also acceptable in their recertification programs. Many do accept them. Non CBH-employeed attendees desiring CEU I credits will be charged a $5 processing fee, and in addition to their name/mailing address, must supply a social security, licensure, or driver’s license number. Due to some folks’ concern about identity theft, we’ve been allowed to take any of the above (three) identification numbers. CBH employees are exempt from the $5 processing fee, but must submit a form with correct information . (Certificates will not be issued without prepayment, current address, and ss/licensure/driver’s license number.)

IF YOU ARE INTERESTED IN CEU I credits, please (LEGIBLY) print:

NAME :

ADDRESS:

City: State: Zipcode:

E-mail:

SOCIAL SECURITY NUMBER
*If you prefer not to list your social security number, please write in your licensure # or driver’s license number

*You may fill in the information on-line, but you must print out and mail this form in to the address listed below.

Please include payment of $5 for CEU I credit, and turn in your payment to Cathi Norton (at presentation),
or—within 5 days of presentation—to her at 645 S. Rogers St., Bloomington, IN 47403. Please make
check payable to “Center for Behavioral Health.”

More information on the Breakfast Learning Series is available at our website: www. the-center.org