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Registration: MOTIVATIONAL INTERVIEWING INTO PRACTICE (MI-IP) FOR NON-CLINICIANS
PLEASE READ PRIOR TO COMPLETING THIS REGISTRATION.
In order to be eligible and register for the Motivational Interviewing Groups series, applicants are required to complete the 4-hour, free self-paced, online course
Tour of MI: An Interprofessional Road Map for Behavior Change
and submit an electronic copy of your certificate of completion during the registration process. Click
TOUR of MI
to take the course.
Name
*
First
Last
Credentials
Agency/Organization
*
Current Position/Job Title
*
Mailing Address
*
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Email Address
*
(by providing your email address, you will automatically be added to the PS ROTA-R mailing list; to opt-out, please contact psrotar@casat.org)
Enter Email
Confirm Email
Password
*
Enter Password
Confirm Password
Strength indicator
Mobile Phone Number
*
(PS ROTA-R Staff will be sending weekly SMS text messages related to series content. By inputting your phone number, you consent to receive text messages sent through an automated texting system.)
What is one thing you want to learn by taking the MI-IP EPL Series?
*
Other than the Tour of MI self-paced course, have you ever attended a Motivational Interviewing training?
*
Yes
No
If yes, please explain
*
What county/counties do you serve?
*
Are you Hispanic or Latino/a?
Yes
No
Prefer not to answer
What is your race?
(select one or more)
Black or African-American
White
American Indian
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other
Prefer not to answer
For American Indian and/or Alaska Native: What is the name of your tribe or community?
Tour of MI Certificate of Completion
*
Upload to system
Max. file size: 64 MB.
By checking here you are indicating that you understand the technology requirement and time commitment to participate in this training.
*
I understand the time commitment involved and agree to fully participate.