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Course Order Form CEUOutlet.com Attention: Lyndsey Herrman 8511 SW 51st St. Topeka, KS 66610 Phone: (785) 845-8455 Fax: (785) 478-0181 Please fill out registration form on-line and then print it out and Fax it or mail it with your check Pre-registration is required. Your E-mail: Profession: Social Work Psychology Pyschiatry Professional Counselors Marriage & Family Therapist Drug & Alcohol Abuse Counselor Case Manager Mental Health Professional Other First Name: Last Name: Organization Name: Work Phone number: - - Home Phone number: - - Mail Address: City: State: (Select your state) Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Island Virginia Washington West Virginia Wisconsin Wyoming Postal Code: - Select Desired Courses: Diagnosing and Treatment Family Diagnosis [6 CE/$69.00] Thorns of Love: Spousal Abuse/Alcohol Diagnosis [6 CE/$69.00] Boys Town PEM Diagnosing Model [10 CE/$99.00] Treating Youth with DSM-IV Disorders [6 CE/$69.00] Ethics Family Ethical Challenges [3 CE/$49.00] Ethical Boundaries in School Social Work [3 CE/$49.00] Ethical Considerations of Blended Families [3 CE/$49.00] Thorns of Love: Spousal Abuse/Alcohol Ethics [3 CE/$49.00] Who Draws the Line? [3 CE/$49.00] Childhood and Family Family Diagnosis [6 CE/$69.00] Thorns of Love: Spousal Abuse/Alcohol Ethics [3 CE/$49.00] Thorns of Love: Spousal Abuse/Alcohol Diagnosis [6 CE/$69.00] The ABC's of Discipline [8 CE/$89.00] Treating Youth with DSM-IV Disorders [6 CE/$69.00] Dangerous Kids (available June)[7 CE/$79.00] Aging and Older Adults Alcohol and Substance Abuse Thorns of Love: Spousal Abuse/Alcohol Ethics [3 CE/$49.00] Thorns of Love: Spousal Abuse/Alcohol Diagnosis [6 CE/$69.00] The Road to Victory [6 CE/$69.00] Enclosed is my check payable to CEUOutlet for $ Please Charge My Credit Card $ Visa      Mastercard Credit Card Number: _________ - _________ - _________ - _________ Expiration Date: _________________ SIGNATURE__________________________________________________ Provide Other Information or Feedback Here: Check this box if you would like to recieve a call

Questions About Seminars or Ordering Study materials? Call Lyndsey Herrman, FSHS, MSW Phone: (785) 845-8455 Fax: (785) 478-0181