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:

__________________________
0112

Certifications/Licenses: CRC CDMS CCM RN NCC LPC Sub Abuse MFT LCSW
NOT ALL COURSES HAVE THE SAME APPROVALS. Refer to the Course Descriptions for details.
Answer sheet must be returned byJuly 1, 2012


24-hour credit card order taking service: Credit Card No. ___________________________________Exp. Date_________

Signature ______________________________________________________ All fees valid through June. 30, 2012

Visa Master Card AMEX Discover Debit

Complete Course
with Text

  Registration
& Exam Only
Counseling Ethics (ETH) $155   $118
$ ________
Health Care Ethics (HCE)
$155
$118
$ ________
Life Care Planning (LCP) NEW
$165
$125
$ ________
Zen and Psychotherapy (ZEN) NEW
$125
$95
$ ________
Different Therapies: One Client (DFT) NEW
$125
  $ 95
$ ________
Rehabilitation Consultant (RCO) $195   $155
$ ________
Dual Disorders (DUL)
$ 95
$ 70
$ ________
Strategic Case Management (STC)
$265
  $195
$ ________
Substance Abuse & Disabilities (SAD)
$ 95
  $ 70
$ ________
Vocational Services and Substance Abuse (VSA)
$ 95
  $ 70
$ ________
Drug Treatment:I (DTA)
$ 95
  $ 70
$ ________
Drug Treatment:II (DTB)
$ 95
  $70
$ ________
Enhancing Responsibility (ENR)
$135
  $105
$ ________
Mental Health Drugs (MHM)
$185
  $155
$ ________
More Effective Interviewing (MEI)
$ 135
  $110
$ ________
Skilled Empathy (SKE)
$155
  $110
$ ________
Ethics for Therapists: Update (TEU) NEW
$195
  $148
$ ________
Understanding Disability (UND)
$ 295
   $235
$ ________
Adults in Transition (TRA) NEW
$ 185
   $120
$ ________
Prepaid Online Registration (ONL)
$ 69
  
$ ________
Subtotal
$ ________
Discount, if applicable:
$ ________
Handling, $15 per complete course w/ text
$ ________
Handling, $7 per exam only course
$ ________
If shipped outside USA, $30 for the first course, $15 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.