To complete your registration, add your desired workshop(s) to your cart and complete payment. Thank you! Information and Consent Form for Training for Beth Richman, LCSW, CADC I Name * First Name Last Name Discipline * Social Worker Psychologist Counselor Psychiatrist Nurse Practitioner Other Discipline, if other Licensure (if applicable) Click here if licensure is pending Licensure pending Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Which training(s) are you registering for? * Polyamory 101 - Dec 4 How did you hear about this training? Disclaimer and Copyright Information 1) I am aware that this training is for my intellectual and clinical growth and: a) This training is not a form of individual or group therapy. b) This training is not a form of individual or group supervision. c) This training is not a form of individual or group consultation. 2) The material presented in this training is the sole intellectual property of the presenter. It is intended to educate and provide clinical growth. I understand and agree not to replicate or reuse the material presented for financial gain or for personal or professional use other than in the ways outlined above. 3) This training may be recorded and uploaded as an educational tool for others. If you ask questions, you may be part of this recording. Your participation is greatly appreciated as the questions asked are often helpful to others. Cancelation Policy * Cancelations must be made 1 week prior to the training to receive a full refund. Cancelations made after that window will not be refunded. I have read and agree to the cancelation policy terms. Signature * By signing below I am stating that I understand and agree with the information on this form and consent to the guidelines of this training. Date MM DD YYYY This form does not complete your registration. Please proceed to your cart and process payment details. Thank you!