First Name:

Address:

City:

Country:

Email:

Organization/Employer: (enter "none" if not applicable)

Job/Position:

Briefly describe your professional background, current role and experience using MI-based approaches:

If you have completed MINT training, please enter the date training was completed. If you have NOT completed MINT training, please summarize MI training you have completed including: title of training program, instructor(s) (whether instructor was MINT-level), date(s) of training and number of hours per event.

Have you completed a formal Motivational Interviewing Treatment Integrity (MITI) coder training program delivered by a MINT trainer?

Yes
No

Has your MI proficiency or skill been documented by a standardized coding of a sample of your work by a MINT professional using the MITI or HCPA?

Yes
No

Please email coding report to hsisupport@healthsciences.org or fax to 1-866-640-6060.

If applicable, please summarize your experience as an MI coder or trainer:

Have you completed Chronic Care Professional (CCP) Certification?

Yes
No

Why have you chosen to pursue HCPA certification?

Do you have any questions about the HCPA training program or certification?

Credit Card Type:

Credit Card Number:

Expiration:

(ex:10/12)

Card Security Code: