MCBClinical Supervision Training Form
DECEMBER CST VIRTUAL TRAINING
Date andTime: December 16-17, 2021 9:00a.m. - 1:00p.m.
Location: Zoom Meeting
Trainer: Scott Breedlove Topic:Clinical Supervision Training
Course Description: This training is a comprehensive 30 hour nationaltraining model for clinical supervision. The first 14 hours are completedonline and this is followed by a 2 day, 8 hour total Zoom training to reinforcethe online training and introduce additional supervision topics. This trainingis required for new supervisors to become a MCB Qualified Supervisor.
You must sign up 1 week in advance tocomplete the online portion of the training!
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Contact Hours: 30 Hours, approved by MCB Confirmation: By E-mail
Cancellations: MUSTbe done 1 week before the training to receive a refund of the registration fee
Toregister: Please print or type your information below and return thisform and registration fee to:
® For checks or money orders payments mail to:MCB, 428 E. Capitol, 3rd Floor, Jefferson City, MO 65101
® For any other payments fax form to (573) 616-2303or e-mail to help@missouricb.com.
® For information, call (573) 616-2300.
Name___________________________________________________________________________________________
Address: ___________________________________________________________________________________________
City, State, Zip: _____________________________________________________________________________________
Home or Cell: (________)____________-_____________________Work: (______)___________-________
Email address:___________________________________________________________________________________
Credentialor License Held: ______________________________________________________________________
(This training is now open to anyone however MCBsupervision numbers will only be assigned at the end of the training to thoseholding one of the following: CRADC, CRAADC, CCJP, CCDP, CCDP-D, RADC, RADC-P, SQP/SQP-R, LPC, LCSW, LMFT or Licensed Psychologist)
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To secure a spot in anyof these trainings the MCB must have your REGISTRATION FORM and FEE inthe office before you will be added to the roster; otherwise you will be placedon a waiting list until fee is received in the office.
Registration Fee: $100.00 EACH new supervisor or $75.00 EACH already approvedsupervisor
If paying by CC: (Visa, MC orDiscover)
Credit CardNumber_____________-_____________-______________-______________ ExpirationDate_______/________
Credit Card 3 DigitVerification Code: ______________
*Note – there is always apossibility of MCB trainings being cancelled if there are not enough participantssigned up. A 1 week notice will be provided to participants and refund checkswill be issued.