Questions

1. Would you be interested in earning a Family Caregiver Counselor Certificate? _____

2. If so, could you attend a 3-day training program? _____

3. Would you prefer a 21-hour distance-delivered training program?

4. If you are interested in earning a FCC, which of the following 2008 dates would be best for you? (write 1 and 2 in order of priority, 1 is top priority)

a. _____October 25 - 26, Marin County
b. _____November 13-14, Los Angeles

5. Are you a nationally certified counselor, state licensed counselor, or California registered counselor? (If so, state which designation/s you hold.)

6. If you do not hold one of the above designations, what related degree/s, license/s or certification/s have you earned?

7. Would a 1-day introduction to Family Caregiving Counseling be of interest to you? ______

8. If you are interested in the 1-day introductory training, which of the following 2008 dates are best for you? (write 1, 2, 3 in order of priority, 1 is top priority)

a. _____September 12, SF Bay Area
b. _____September 26, SF Bay Area
c. _____November 6, Los Angeles, CA

Your Name: (first)________________, (last)_________________

Your Phone: (land)________________, (cell)_________________

Address: (institution) _______________________, (P.0. or street) _______________, (city/town) ___________________, (state) _________________, (zip) ___________ 

After you have filled out this survey, please copy and paste this survey into an email (subject: FCC Survey)  and send the filled-out survey to: Sally Gelardin, sal @gelardin.net. For more information, call 415.312.4294 or view AgingWorks.org