Registration Form

Responding to Survivors with
Substance Abuse and Mental Health Issues

A two-day training for providers of residential services
in the Northeast and Central Regions

free to all who provide residential services under DSS contracts
in the Northeast and Central Regions

Wednesday, May 14, and Monday, May 19, 2008
 The Essex Conference Center and Retreat, Essex, Massachusetts
9:30 a.m. to 3:30 p.m.
Continental breakfast and networking begin at 9:00

Lunch will be provided.

Please register by April 30, 2008.

Special instructions for filling out this registration
  • A separate registration is needed for each individual attending.
  • It is important that you fill in each box and answer every question. If you do not have an email address, be sure to include a work phone number.
  • Please use your mouse or the tab key to go through the registration. If you hit "enter" before completing the registration, it will be sent uncompleted.
  • If you have not received a confirmation from us within a week, please contact us.
  • Thank you for your interest in this training.
Your Name:
Your Agency or Organization:
Agency Address:
Your Position:

Your Phone Number:
Your Email:
In order to insure that this training is most useful to you, please answer the following questions:
How familiar are you with complex PTSD?
      Very familiar       Somewhat familiar       Not very familiar

How familiar are you with the relational theory?
      Very familiar       Somewhat familiar       Not very familiar

How familiar are you with stages of change theory?
      Very familiar       Somewhat familiar       Not very familiar

How familiar are you with motivational interviewing?
      Very familiar       Somewhat familiar       Not very familiar
For how long have you worked in the domestic violence field?
      Less than 1 year       Between 1 and 3 years       More than 3 years

For how long have you worked at your agency?
      Less than 1 year       Between 1 and 3 years       More than 3 years
If you find that you cannot register online, you can print this form, complete it, and send it to us by mail at our new address (Northnode, P.O. Box 130, Roslindale, MA 02131) or by fax (617-522-2515). Thank you.