Level 1 Micro-Credential Registration Survey
Level 1 Micro-Credential Registration
4/17/2024 4:33:05 PM
Page 1 of 1
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.
Alternate Phone
*
Please include Country Code and Area Code.
11.
Email Address
*
12.
URL of Agency or Private Practice
Examples:
- www.youragency.com
- www.yourprivatepractice.ca
13.
Highest Level of Education
*
-- Please Select --
Undergraduate degree
Master's degree
Doctoral degree
14.
Field of Study
*
15.
Years of Experience in Face-to-face Counselling
*
16.
Years of Experience Using the Internet and Email
*
17.
Professional Association in Which You Are a Member
*
In full; please do not abbreviate.
18.
Membership Number
If your membership number contains non-alpha-numeric characters, leave this field blank.
19.
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
20.
Please tell us how you found out about our training.
*
E.g. - website, workshop (please indicate who conducted the workshop), referral from an individual or agency.
