Education Development Center, Inc. • 43 Foundry Avenue • Waltham, MA 02453 • amsr@edc.org

Please complete one proposal for each AMSR workshop.

Training Type: Regular New Leader Training/NLT (train the trainer) Revised Feb. 2019

Training Curriculum: Outpatient Inpatient Direct Care Outpatient Direct Care Inpatient Substance Use Disorder

Training Date: Today’s Date:

Sponsoring Organization:

Sponsoring Organization's Mailing Address:

Point of Contact (POC) at Sponsoring Organization:

Email Address: Phone Number:

Training Venue:

Name of Venue:

Street Address (No., Street, Unit/Suite No., Floor, City, State, Zip):

Is this venue accessible to persons with disabilities? Yes No

Trainer 1

Name:

Academic Credentials (i.e. MSW):

Employer's Name:

Email Address:

Phone Number:

Alt. Email (Optional):

Trainer 2 (if applicable)

Name:

Academic Credentials (i.e. MSW):

Employer's Name:

Email Address:

Phone Number:

Alt. Email (Optional):

Participant Manual Delivery

Total number of manuals to be delivered (max/training: 50 regular, 30 NLT): No. of regular attendees: Grad students:

Manual Recipient Name: Phone Number:

Email Address:

Mailing address for the manuals (Building/org name, Number, Street, Unit/Suite, Floor, City, State, Zip) (NO PO Boxes):

Registration

Who will manage registration? Sponsor AMSR May we advertise your workshop to the general public? Yes No

If yes: Registration fee paid by participants, if any: $ Start time: End time:

Registration information (if managed by sponsor):

Continuing Education Credits

AMSR provides 6.5 hours of continuing education (CE) credits by the following boards at no charge: APA, NBCC, NASW, and NYSED State

Board of Social Work. The credits provided by NASW and NBCC are accepted by the California Board of Behavioral Licenses for LMFT,

LCSW, LPCC, and LEP.

Continuing Medical Education (CME) credits through the American Medical Association (AMA) are also available at an additional cost of

$100 per training plus $10 per applicant. Proposals requesting AMA CME credits must be submitted no less than 35 days prior to training.

Will participants require AMA CME credits? Yes No

Contract

Contract Signatory Name (must have signing authority for sponsoring org):

Title: Email Address:

Phone Number:

Invoicing

You will be invoiced based on the number of manuals delivered, trainer costs, and optional AMA CME fees. Costs are non-refundable.

Invoice Recipient Name: Email Address:

Mailing Address: Phone Number:

How did you find out about AMSR?

AMSR/SPRC Webinar AMSR Trainer Conference External referral GLS Grantee

Internal referral Web Zero Suicide Event Other:

Assessing and Managing Suicide Risk (AMSR)

Workshop Proposal Form