DBT Clinicians Applied Course Attestation Form

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Participation Statement*

I participated in the training, DBT Clinicians Applied Course with Christopher Conley, DSW & Erica Tan, PsyD on January 8-12, 2024 from 8:30am-4:00pm PT. Please accept this as verification that I participated in the event in its entirety.

I have read and agree to the statement above.

Name

First Last

Profession/Discipline:

On the line below, please enter your full name and licensure, EXACTLY as you would like it to appear on your CE certificate.*

Example: Jane Doe, PhD, CADC I

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I confirm the single line above contains my name and licensure exactly as I want displayed on my CE certificate.

Yes, I confirm that the line above contains exactly what will be shown on my CE certificate.

Email address where you would like your CE certificate delivered.*

Can we send you information about upcoming trainings?

Yes

Signature*

By signing below, I verify that I attended this event in its entirety.

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DBT Clinicians Applied Course Attestation Form

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