Supplemental Training Registration Form

    Email Address

    First Name

    Last Name

    Organization

    National Provider Identifier

    What is your race? (Check all that apply)
    WhiteBlack or African AmericanAmerican Indian or Alaska NativeAsian IndianCambodianChineseFilipinoHmongJapaneseKoreanLaotianVietnameseNative HawaiianGuamanian or ChamorroSamoanDo not wish to discloseOther

    Please specify:

    Are you Hispanic, Latino/a, or Spanish origin

    Please specify:

    Do you see Medi-Cal patients?
    YesNoUnsure

    Service Location Street

    Service Location Additional

    Service Location City

    Service Location State/Province

    Service Location Postal Code

    Occupation/Provider Type

    Please specify:

    Please identify your area of specialization

    Please specify:

    Have you completed the ACEs Aware “Becoming ACEs Aware in California” online training)? Certified Core Trainings include the Becoming ACEs Aware in California online training or a Core Training provided by one of the five following organizations: 1. Cottage Health (Pediatric Resiliency Collaborative), 2. Futures Without Violence, 3. Riverside County Department of Public Health, 4. The Children’s Clinic, or 5. UCSF Benioff Children's Hospital – Child and Adolescent Psychiatry Portal & Center for Community Health and Engagement.
    YesNoNot yet, but I plan to in the next year.

    If you are a Medi-Cal provider, have you attested to completing a certified ACEs Aware Core Training?
    YesNoUnsureNot applicable

    Are you screening patients for ACEs?

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