Teach a Course

* are required fields

Name*:  

Credentials*: 

Home Address*: 

City, State, Zip*: 

Email*: 

Daytime Phone*:  

Evening Phone: 

Fax:  

Area of Clinical Expertise*: 

Work Experience*:  

Number of Years as a Practicing Clinician*:  

Facility where Currently Employed*:  

Do you have prior teaching experience?:   yesno

What topic(s) would you like to teach? Feel free to elaborate on details*.

Have you taught this topic before?  yesno

Have you taught this course in the past 3 years?  yesno

How many hours is this course?

How many times have you taught this course in the past 3 years? Where?  

Please tell us a little about yourself, your teaching skills and your area of clinical expertise: