Continued Professional Development Workshops Full Name * First Name Last Name Date * MM DD YYYY Preferred Pronouns * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Neurodivergent. Please specify: Neurodivergent. Diagnosis Type: Formal Diagnosis Self Diagnosis Which Workshop are you applying for? * Deconstruction of theory and practice through an intersectional lens with Victoria Baskerville Queer identities and GSRD inclusive practice with Victoria Baskerville A Transcultural and Intersectional Ego State Model of the Self with Victoria Baskerville Professional Development and Exam Preparation Group with Victoria Baskerville I have a disability / health / learning difficulty * Yes No Thank you for submitting your application. If you experience any issues with this process, please email us.