Compassionate Bereavement Care Certification Application

Address*

Geocoder

Primary Contact First Name*

Primary Contact Last Name*

Email*

Primary Contact Email (publishable for online listing)*

Provider Name (publishable for online listing)*

Provider Phone (publishable for online listing)*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Provider Type*

Business and/or Services Description*

Provider Business Email*

Fax

Provider Website

Days/Hours of Operation

Optional - providing this with your request can help speed up the listing process. This can be modified after approval.

Costs
Application Fee (non-refundable, pay online below) - $30
Registration fee (4 days) - $995
Continuing Education Credit and Certificate - $200

Hotel Lodging - (paid separately). Please see the Travel Info link on your desired course page to make your reservations at our negotiated rate at our host hotel.

Will you be paying registration and CE fees by check or by PayPal/Credit Card?*

PayPal / Credit Card
Check

Please indicate which course you plan on attending*

Sept. 22-25, 2022 - Sedona, AZ

Please select either live stream video conference or in-person training below.*

I'll attend via live stream video conference
I'll attend via in-person training located at Selah Carefarm

Education and Employment

Educational History*

List universities/academic programs/graduation dates. Additionally, what academic training do you have in traumatic death and grief?*

What experience do you have personally or professionally in traumatic death and grief?*

What is your volunteer experience within the past 24 months?*

If you have had a personal loss of your own, please list the ways in which you coped with your loss. (I.e. counseling/therapy, faith, medication, prayer, friends and family, etc.)*

Please understand that the nature of this course is very intense. Do you feel prepared to integrate personal experience with professional wisdom at a very deep and intimate emotional level?*

Yes
No

License Number*

If you do not have a license number, please type in the word "other" into the field

Current Employer*

Since*

What is your work experience within the past 24 months?*

Additional Questions/Comments/Information

Please let us know if you have any questions or would like to provide any additional information with your request.

ACKNOWLEDGEMENT*

By checking this box, I acknowledge that I have read and agree to the following statement and that I commit to the standards of practice outlined in the Clinical Care Principles.

Completion of the Compassionate Bereavement Care® Certification course does not automatically warranty our referral to you as a provider. We take our clients' feedback seriously and reserve the right to cease referrals should repeated concerns be brought to our attention. We require commitment to the standards of practice outlined in the Clinical Care Principles.

Confirmation of Intent*

By checking this box I affirm that I am fully prepared at this time to commit to this training program if accepted.

Application Fee*

Price: $30.00

(Non-refundable application processing/handling fee)

Application Fee

$0.00

(Non-refundable application handling/processing fee)

Admin Code (Only if requested by MISS)

Credit Card

Card Details

Cardholder Name

Compassionate Bereavement Care Certification Application

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