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Strong4Life Healthcare Providers & Clinicians Training Registration

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Survey Date (auto-populated, not seen on public survey)
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M-D-Y

Please select the training you would like to attend:

* must provide value

Foundations of Motivational Interviewing

Building Resilience: Promoting Regulation (Newly updated)

Raising Healthy Eaters

Supportive Conversations: Addressing Positive Mental Health Screens (New!)

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For more information of these trainings, visit our website here: https://www.strong4life.com/en/clinicians

Which Supportive Conversations: Addressing Positive Mental Health Screens training would you like to attend?

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Provider

Subspecialist

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Which year would you like to see dates for?

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2025

2026

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No dates are available for this year. Please choose a different year to see available dates.

Which of the following training dates would you like to attend for Foundations of Motivational Interviewing?

* must provide value

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Which of the following training dates would you like to attend for Raising Healthy Eaters?

* must provide value

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Which of the following training dates would you like to attend for Building Resilience?

* must provide value

Tuesday, December 2 (12:30 - 1:30 p.m.)

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Which of the following training dates would you like to attend for Foundations of Motivational Interviewing?

* must provide value

Thursday, February 12 (12:00 - 1:30 p.m.)

Thursday, May 7 (12:00 - 1:30 p.m.)

Thursday, September 24 (12:00 - 1:30 p.m.)

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Which of the following training dates would you like to attend for Raising Healthy Eaters?

* must provide value

Tuesday, February 10 (12:00 - 1:00 p.m.)

Tuesday, May 5 (12:00 - 1:00 p.m.)

Tuesday, September 22 (12:00 - 1:00 p.m.)

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Which of the following training dates would you like to attend for Building Resilience: Promoting Regulation?

* must provide value

Tuesday, February 3 (12:30 - 1:30 p.m.)

Tuesday, April 7 (12:30 - 1:30 p.m.)

Tuesday, June 9 (12:30 - 1:30 p.m.)

Tuesday, August 4 (12:30 - 1:30 p.m.)

Tuesday, October 6 (12:30 - 1:30 p.m.)

Tuesday, December 1 (12:30 - 1:30 p.m.)

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Which of the following training dates would you like to attend for Supportive Conversations: Addressing Positive Mental Health Screens?

* must provide value

Wednesday, March 4 (12:30 - 1:30 p.m.)

Wednesday, May 6 (12:30 - 1:30 p.m.)

Wednesday, July 8 (12:30 - 1:30 p.m.)

Wednesday, September 2 (12:30 - 1:30 p.m.)

Wednesday, November 4 (12:30 - 1:30 p.m.)

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Which of the following training dates would you like to attend for Supportive Conversations: Addressing Positive Mental Health Screens?

* must provide value

Wednesday, February 4 (12:30 - 1:30 p.m.)

Wednesday, April 8 (12:30 - 1:30 p.m.)

Wednesday, June 10 (12:30 - 1:30 p.m.)

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First name:

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Last name:

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Email:

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Phone number:

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Sex:

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Male

Female

Other

Prefer not to answer

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Race and Ethnicity: (Select all that apply)

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American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Prefer not to answer

Credentials: (Select all that apply)

If credential is not listed, select 'other'

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MD/DO Pediatrics

MD/DO Ped Sub

MD/DO Family Med

MD/DO OB/GYN

MD/DO Other

MD/DO Resident

MD/DO Student

MD Psychiatrist

Psychologist (PhD or PsyD)

LCSW

LPC

PA Student

NP Student

RN Student

LPN

Dietetic Intern

CNM (Certified Nurse Midwife)

CNM Student

MPH

PhD

IBCLC/CLC

CPA (Certified Professional Authority-WIC)

Other (please specify):

None

National Provider Identification (NPI) Number:

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Year of licensure:

Full Practice name or organization:

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What is the full practice or organization name?

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Branch location name:

Only if your practice or organization has multiple locations

Example: For Children's Healthcare of Atlanta, Scottish Rite would be a branch location name.

Mailing address:

Please provide the address for the practice or organization.

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City:

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Other city:

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State:

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County:

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Zip code:

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Is this a private practice?

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Yes

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Please list your delegating physician:

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How many clinicians are at your specific practice location?

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Estimated percent of Medicaid patients:

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1% - 25%

26% - 50%

51% - 75%

76% - 100%

Unsure

Prefer not to answer

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Are you the primary contact for ordering resources/materials?

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Yes

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Please provide the best name and email for corresponding about resources/material orders:

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Yes

CME

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MOC Part II

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Please sign for CME Credit:

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Add signature

Stark Law Disclaimer: In order for Children's to meet Stark Law regulatory requirements that allow Children's to provide a limited amount of non-monetary compensation to physicians, we must note your participation in this CME activity at a value of $32 per credit hour for live events and $25 per credit hour for virtual events. This amount will be applied to your non-monetary compensation allowance. No action is required on your part, and you will be notified if you are nearing the limit by the physician education team. The total non-monetary compensation allowed for 2026 is $535.

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Strong4Life Healthcare Providers & Clinicians Training Registration

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Practice or Organization Information

Continuing Education Credit

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