CM HOME STUDY REGISTRATION FORM
Please PRINT OUT this form and mail, fax, or phone your registration to CM Home Study.


Print Name _____________________________________

Ship To ________________________________________

Address________________________________________

City______________________ State____ Zip_________

Phone (_____)______________________ Day Eve


Please place my name
on your mailing list.

Please place my name
on your e-mail list.

E-mail address:

__________________________
1118

Certifications/Licenses: CRC CDMS CCM RN Other
NOT ALL COURSES HAVE THE SAME APPROVALS. Refer to the Course Descriptions for details.
Answer sheet must be submitted by November 15, 2018

Credit Card No. _________________________________ Exp. Date__________

3 Didget Security Code_________

Signature ______________________________________________________


Visa Master Card AMEX Discover Debit

Complete Course
with Text

  Registration
& Exam Only
Rehabilitation of Emerging Disabilities (RED) NEW $ 195 $ ________ $ 95
$ ________
Psychological Issues of Medical Disorders (PMD) NEW $ 135 $ ________ $ 95
$ ________
Counseling Older Adults (COA) NEW $ 195 $ ________ $ 115
$ ________
Ethical Counseling Issues (COU) $ 175 $ ________ $ 95
$ ________
Ethical Decision Making (EDM) NEW $ 185 $ ________ $ 105
$ ________
Check Box Neuropsychology and Work Injuries (NPW)
$ 205
$ ________ $ 120
$ ________
Check Box Mental Health Diagnosis (MHD) NEW
$ 125
$ ________ $ 95
$ ________
Check Box Zen and Psychotherapy (ZEN)
$ 135
$ ________ $ 95
$ ________
Check Box Dual Disorders (DUL)
$ 115
$ ________ $ 95
$ ________
Check Box Substance Abuse & Disabilities (SAD)
$ 115
$ ________ $ 95
$ ________
Check Box Vocational Services and Substance Abuse (VSA)
$ 115
$ ________ $ 95
$ ________
Check Box Drug Treatment:I (DTA)
$ 115
$ ________ $ 95
$ ________
Check Box Drug Treatment:II (DTB)
$ 115
$ ________ $ 95
$ ________
Check Box More Effective Interviewing (MEI)
$ 145
$ ________ $ 110
$ ________
Check Box Skilled Empathy (SKE)
$ 175
$ ________ $ 110
$ ________
Check Box Adults in Transition (TRA)
$ 195
$ ________ $ 120
$ ________
Check Box Grief Counseling (GRI)
$ 135
$ ________ $ 80
$ ________
Check Box Prepaid Online Registration (ONL)
$ 89
$ ________    
         
         
         
         
Subtotal
$ ________
Discount, if applicable:
$ ________
Shipping & Handling, $15 per complete course w/ text
$ ________
Shipping & Handling, $7 per registration / exam only course ($25 if outside the US)
$ ________
If shipped outside USA, $45 for the first course, $18 for each additional course (Customs not included)
$ ________
TOTAL ORDER
$ ________

FOR FAST SERVICE ORDER by FAX (805-484-7677) or PHONE (805-383-9010) with your Visa, Master Card, AMEX, Discover, or Debit Card

OR

Mail credit card order, check or money order in U. S. Dollars (payable to CM Home Study) to:
CM Home Study, 6082 Paseo Encantada, Camarillo, CA 93012
Questions? (805) 383-9010 or
e-mail us at: Mail@CMHomeStudy.com
Thank you for your order.