DBT in a Nutshell, Skills, and Working Well with Suicidal Clients Attestation Form

Participation Statement*
I participated in the training, DBT in a Nutshell, Skills, and Working Well with Suicidal Clients with Ashley Maliken, PhD, DBT-LBC and Ajeng Puspitasari, LP, PhD on December 14 – 15 & 18 – 19, 2023 from 8:00am-4:30pm PT. Please accept this as verification that I participated in the event in its entirety.
- I have read and agree to the statement above.
Name
First Last
Profession/Discipline:
On the line below, please enter your full name and licensure, EXACTLY as you would like it to appear on your CE certificate.*
Example: Jane Doe, PhD, CADC I
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I confirm the single line above contains my name and licensure exactly as I want displayed on my CE certificate.
- Yes, I confirm that the line above contains exactly what will be shown on my CE certificate.
Email address where you would like your CE certificate delivered.*
Can we send you information about upcoming trainings?
- Yes
- No
Signature*
By signing below, I verify that I attended this event in its entirety.

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