Registration Form

What: Hoarding Training and Supervision Group  Day-Long Intensive

Where: Office of Mark Chidley, LMHC  11595 Kelly Road, Ste. 312 , Fort Myers, FL   33908

MARK A. CHIDLEY, LMHC has been approved by the Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling. This course has been approved for 7.0 CEU’s.
CE Provider #: 50-13579


Breakfast Snacks and Coffee will be provided/Lunch on Our Own

When: April 13, 2012   8:45 am – 5:00 pm

Cost: $75  before March 30    $90  after March 30  (registered students $60)

Please Make Checks Payable to: Mark Chidley, LMHC. Group size is limited to 12 participants

Cancellation Policy: There is very limited space in the Hoarding Training experience to strengthen group cohesion and allow for more individualized attention from the trainer. You are reserving your space in the training with a payment before the training begins. If there is an emergency/crisis that requires you to miss the training, your fee will be refunded provided you call Mark Chidley (239-728-1886)directly to discuss this at least 24 hours before the training date.

Please fill out and mail this form with payment to above address  by March 30, 2011.  You will not be registered until payment is received.


Name: _______________________

Agency or Company: __________________________________

Address: ____________________________________________

Phone: ______________                Email:____________________

___ LCSW  ___ RN ___ LMHC  ___CAP ___ LMFT __ Registered Intern

___ Psychologist _________________  Other (specify)

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