MCB Clinical Supervision Training Form
OCTOBER CST VIRTUAL TRAINING
Date and Time: October 21-22, 2021 9:00a.m. - 1:00p.m.
Location: Zoom Meeting
Trainer: Scott Breedlove Topic: Clinical Supervision Training
Course Description: This training is a comprehensive 30 hour national training model for clinical supervision. The first 14 hours are completed
online and this is followed by a 2 day, 8 hour total Zoom training to reinforce the online training and introduce additional
supervision topics. This training is required for new supervisors to become a MCB Qualified Supervisor.
You must sign up 1 week in advance to complete the online portion of the training!
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Contact Hours: 30 Hours, approved by MCB Confirmation: By E-mail
Cancellations: MUST be done 1 week before the training to receive a refund of the registration fee
To register: Please print or type your information below and return this form and registration fee to:
→ For checks or money orders payments mail to: MCB, 428 E. Capitol, 2
nd
Floor, Jefferson City, MO 65101
→ For any other payments fax form to (573) 616-2303 or e-mail to help@missouricb.com.
→ For information, call (573) 616-2300.
Name______________________________________________________________________________________________
Address: ___________________________________________________________________________________________
City, State, Zip: _____________________________________________________________________________________
Home or Cell: (________)____________-_____________________ Work: (______)___________-___________________
Email address:_______________________________________________________________________________________
Credential or License Held: ____________________________________________________________________________
(This training is now open to anyone however MCB supervision numbers will only be assigned at the end of the training to
those holding one of the following: CRADC, CRAADC, CCJP, CCDP, CCDP-D, RADC, RADC-P,
SQP/SQP-R, LPC, LCSW, LMFT or Licensed Psychologist)
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To secure a spot in any of these trainings the MCB must have your REGISTRATION FORM and FEE in the
office before you will be added to the roster; otherwise you will be placed on a waiting list until fee is received in
the office.
Registration Fee: $100.00 EACH new supervisor or $75.00 EACH already approved supervisor
If paying by CC: (Visa, MC or Discover)
Credit Card Number_____________-_____________-______________-______________ Expiration Date_______/________
Credit Card 3 Digit Verification Code: ______________
*Note – there is always a possibility of MCB trainings being cancelled if there are not enough participants signed up. A 1 week notice will be
provided to participants and refund checks will be issued.
