The Connecticut Women’s Consortium
Improving Behavioral Health Services for Women
2321 Whitney Avenue, Suite 401
Hamden, CT 06518
phone (877) 731-4925 / (203) 909-6888 x33 or 30
fax (203) 909-6894
trainer@womensconsortium.org
Registration Information Directions

In order to register for a training event, please fill out the form below. If you have questions in the process of completing this form, please contact our Training office at (203) 909-6888 x 30.

Participant Information

* indicates a required field

*Last Name

*First Name

MI

*EMPLOYMENT

I work for...

  
Employee DMHAS employee# 
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Zip

*Phone Numbers

Work Phone / ext Work Fax
Home Phone / ext Home Fax

*Email Address

An email address is required for online registration. If you do not have an email address, then please complete a Paper Registration Form and submit via postal mail or fax.
Functional job title

Select your certification / licensure
(select all that apply)

APRN

CADC

LMFT

LADC

LPN

LCSW

LPC 

RN

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Select your highest degree

AA

AS

BA

BS

BSN

BSW

MA

MS

MSN

MBA

MD

MFT

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PHD

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Do you need specialized services?

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If yes, please describe services needed

 
Final 4 digits of your Social Security #   why do we ask for this?



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If you have questions, please contact our Training office at (203) 909-6888 x33 or 30 or trainer@womensconsortium.org