First Name*

Last Name*

Credentials

License #

Licensure State - Select One - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Address*

City*

State* - Select One - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Phone(XXX-XXX-XXXX)*

Email*

Job Title(e.g., Nurse, LMHP, social worker, student)*

Employer/Affiliation*

Which of the following best describes you? (Please select all that apply.)* BHECN ARPA Awardee
BHECN Graduate Training Stipend Program participant
Lifelong Learning Fund recipients
Behavioral health provider
Community member
Legislator or legislative staff
Academic partner
Behavioral health student or trainee
Professional association representative
Behavioral health regional administrator
Other

If other, please specify

If you are a BHECN ARPA Awardee, what project number do you represent? (This is your 3-digit application number.)

Type of Credit* ANCC (nursing credit)
LADC
APA (psychology/licensed mental health provider credit)
Not Applicable

Which of the following workshops interests you? (Please select all that apply.)* Strategic Grant Writing: From Planning to Impact
Data Resources to Enhance Grant Applications
Advocacy in Action: Strengthening Nebraska's Behavioral Health Workforce
Bridging Gaps in Telebehavioral Health: Best Practices for Reaching Rural and Access-Limited Populations
There and Back Again: Solutions for Successful Transitions of Care
Building and Sustaining Community Partnerships

Do you plan to attend the Networking Hour from 3:45 PM - 5:00 PM? * - Select One - Yes No

Dietary Preferences or Restrictions: Please specify (e.g., vegetarian, vegan, gluten-free, allergies) *

Accessibility or Special Accommodations Needs: Do you require any accommodation to participate in the workshop? If yes, please describe *