Level 1 Micro-Credential Registration Survey
Level 1 Micro-Credential Registration
6/23/2025 1:24:17 PM
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1.
First Name
*
2.
Last Name
*
3.
Street Address
*
4.
Address (continued)
5.
City
*
6.
Province/State
*
7.
Country
*
8.
Zip/Postal Code
*
9.
Primary Phone
*
Please include Country Code and Area Code.
10.
Email Address
*
11.
URL of Agency or Private Practice
Examples:
- www.youragency.com
- www.yourprivatepractice.ca
12.
Highest Level of Education
*
-- Please Select --
Undergraduate degree
Master's degree
Doctoral degree
13.
Field of Study
*
14.
Years of Experience in Face-to-face Counselling
*
15.
Professional Association in Which You Are a Member
*
In full; please do not abbreviate.
16.
Please indicate which Micro-Credential(s) you wish to take. If you are unsure of a Micro-Credential simply check the Maybe box. If you wish to take the full course check all Modules under Definitely.
*
Definitely
Maybe
No
Micro-Credential 1 - Video
Micro-Credential 2 - Chat
Micro-Credential 3 - Email
