Adult Mental Health First Aid

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Select the cohort you are registering for

First Name

Last Name

Title/Role

Phone Number

Agency (please put NONE if unaffiliated)

Email

Address

I reside in Arizona

Yes

No

Are you a behavioral health care provider ?

Yes

No

Special Populations served by me/my agency, please check all that apply

Faith Community

Youth

Elderly

LGBTQ

Veterans

Other

This is a certification training and I must attend the entire workshop and pass the participant exam.

I understand

The self-paced portion of the training must be completed in order to participate in the live/virtual session.

I understand

Your Initials Here

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Today's Date

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Adult Mental Health First Aid

Please fill in your details.

Select the cohort you are registering for

First Name

Last Name

Title/Role

Phone Number

Agency (please put NONE if unaffiliated)

Email

Address

I reside in Arizona

Yes

No

Are you a behavioral health care provider ?

Yes

No

Special Populations served by me/my agency, please check all that apply

Faith Community

Youth

Elderly

LGBTQ

Veterans

Other

This is a certification training and I must attend the entire workshop and pass the participant exam.

I understand

The self-paced portion of the training must be completed in order to participate in the live/virtual session.

I understand

Your Initials Here

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Today's Date

Created with

Adult Mental Health First Aid