Account Registration

First Name *

Last Name *

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Preferred Name

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Job Title/Role *

Organization/Agency/Institution Name *

Organization Type

Country *

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Are you a licensed or credentialed mental health provider? *

If you are a licensed or credentialed mental health professional, please list your professional license type. If you are not a licensed mental health professional, please write N/A. *

If you are a licensed or credentialed mental health professional, please list your licensing state. If you are not a licensed mental health professional, please choose N/A. *

If you are a licensed or credentialed mental health professional, please state your license number. If you are not a licensed mental health professional, please write N/A. *

How long have you been in your profession?

Have you previously taken training or have experience in violence prevention? If so, please describe:

How did you hear about this course?