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Bipolar Disorder and Co-Occurring Substance Use Disorders

October 18, 2016 @ 12:00 pm - 1:30 pm

Free – $15

ABOUT THE PROGRAM

Substance use disorders can be prevalent among individuals who have bipolar disorder. We will discuss clinical presentation and implications for treatment of substance use disorders when co-occurring with bipolar disorder.

Click here for event flyer.


1.5 CEUs offered for LPC, LMFT, LCSW, and Clinical Psychologist.


REGISTRATION IS REQUIRED FOR ALL ATTENDEES PRIOR TO THE EVENT. Check in will begin 15 minutes prior to the program beginning.  Due to video filming, late attendees will be asked to view the presentation in the Green Room.


In collaboration with DBSA Greater Houston

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ABOUT THE SPEAKER


Selvaraj-SudhakarSudhakar Selvaraj, MD

Dr. Sudhakar Selvaraj is an Assistant Professor at the department of Psychiatry and Behavioral Sciences at UT health science center Houston. He is also the Director of UT Health student counselling center, Houston. He qualified in medicine in India and completed clinical psychiatry residency training at Oxford and at Maudsley Hospital and Institute of Psychiatry, London, United Kingdom. He studied the role of serotonin transporters in major depressive disorders for his PhD under the supervision of Professor P.J. Cowen at the department of psychiatry, University of Oxford, UK.

He has broad experience in clinical psychiatry, with specific interest in treating and managing patient with mood disorders such as major depression, bipolar disorder, and anxiety disorders. He has developed expertise in managing ADHD and obsessive-compulsive disorder and in addition, he has substantial experience in managing treatment resistant schizophrenia and early psychosis symptoms. He sees patients at UT Center for Excellence on Mood Disorders and also provide psychiatric care at UTHealth student counseling center.

His research has primarily focused on understanding the neurobiological mechanisms underlying the mood and psychotic disorders. He has specific training and expertise in brain imaging techniques, both structural and functional Magnetic Resonance Imaging/Spectroscopy and Positron Emission Tomography (PET) imaging and its applications in neuropsychiatric disorders. His initial research work was focused on elucidating the role of serotonin transporters (SERT) in major depressive disorder. In a series of studies using Positron Emission Tomography (PET) in conjunction with [11C]DASB, a highly selective 5-HTT radioligand, his team found that abnormalities in SERT availability represent a state abnormality in patients with major depression, which resolves with clinical recovery. These are the first studies in the world investigating SERT in different stages of depression, i.e acute and recovered depression. In another [11C]DASB study, he showed that brain SERT binding in recreational ex-users of 3,4-methylenedioxy-methamphetamine (MDMA), is similar to health control subjects. This finding is of high public health importance as it indicated that neurotoxic effect of acute MDMA use on SERT normalized when MDMA use is discontinued.

His team showed the feasibility of measuring brain serotonin activity using multimodal functional MRI and PET and he demonstrated the direct effect of commonly prescribed antidepressant citalopram on in-vivo 5-HT and on emotion regulation. These studies attempt to unravel the antidepressant treatment mechanisms which could have a major impact in the pathophysiology of mood disorder. He is currently investigating the role of neuroinflammation and oxidative stress in the development of psychiatry illnesses such as mood and psychotic disorders. His team has recently shown that a protein called TSPO or translocator protein (a marker of microglial activation and neuroinflammation) is elevated both in young people at risk of developing psychosis and in patients with schizophrenia. This is the first study investigating brain immune activation in young people with high risk of psychosis. This study is published in American Journal of Psychiatry.

His research has been published in a number of highly cited journals, including American Journal of Psychiatry, Molecular Psychiatry, Biological Psychiatry, Neuropsychopharmacology, British Journal of Psychiatry, Journal of Neuroscience, Psychological Medicine, Bipolar disorder, Neuroscience and Biobehavioral Reviews etc. He has been a recipient of a number of awards and honors, including the National Institute on Drug Abuse (NIDA) travel award, International Society of CNS trial and methodology New Investigator award, American society of psychopharmacology (ASCP) Fellowship Award, American College of Neuropsychopharmacology travel award (ACNP); 2008 Neuroreceptor Mapping Conference travel award; European College of Neuropsychopharmacology (ECNP) Young Scientist Fellowship Award and ECNP Best Research poster award; British Association of Psychopharmacology post-doctoral Bursary Award; ECNP  Young Investigator Award; Patricia-Knapp travel award from St Catherine’s College, Oxford; Guarantors of Brain Travel Grant; and the Dennis Hill Prize, King’s College London. His past research was supported by Medical Research Council (UK) core grants and Academy of medical sciences clinical lecturer (UK) start up grant

 

Register

Details

Date:
October 18, 2016
Time:
12:00 pm - 1:30 pm
Cost:
Free – $15
Event Category:
Event Tags:
, , , , , , , ,

Venue

Auditorium
717 Sage Road
Houston, TX 77056 United States
+ Google Map
Phone:
713.871.1004
Website:
hopeandhealingcenter.org
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>Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' 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>Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option></select> <label for='input_1_16_6' id='input_1_16_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_17" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_17"><label class='gfield_label gfield_label_before_complex' >Work Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_17' > <span class='ginput_full address_line_1 ginput_address_line_1' id='input_1_17_1_container' > <input type='text' name='input_17.1' id='input_1_17_1' value='' aria-required='true' /> <label for='input_1_17_1' id='input_1_17_1_label' >Street Address</label> </span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_1_17_2_container' > <input type='text' name='input_17.2' id='input_1_17_2' value='' aria-required='false' /> <label for='input_1_17_2' id='input_1_17_2_label' >Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city' id='input_1_17_3_container' > <input type='text' name='input_17.3' id='input_1_17_3' value='' aria-required='true' /> <label for='input_1_17_3' id='input_1_17_3_label' >City</label> </span><span class='ginput_right address_state ginput_address_state' id='input_1_17_4_container' > <input type='text' name='input_17.4' id='input_1_17_4' value='' aria-required='true' /> <label for='input_1_17_4' id='input_1_17_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip' id='input_1_17_5_container' > <input type='text' name='input_17.5' id='input_1_17_5' value='' aria-required='true' /> <label for='input_1_17_5' id='input_1_17_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country' id='input_1_17_6_container' > <select name='input_17.6' id='input_1_17_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Réunion' >Réunion</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option></select> <label for='input_1_17_6' id='input_1_17_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_20" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_20"><h2 class="gsection_title"></h2></li><li id="field_1_14" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_14"><label class='gfield_label gfield_label_before_complex' >Are you of Hispanic/Latino/Spanish origin?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_14'><li class='gchoice gchoice_1_14_1'> <input class='gfield-choice-input' name='input_14.1' type='checkbox' value='Yes' id='choice_1_14_1' /> <label for='choice_1_14_1' id='label_1_14_1'>Yes</label> </li><li class='gchoice gchoice_1_14_2'> <input class='gfield-choice-input' name='input_14.2' type='checkbox' value='No' id='choice_1_14_2' /> <label for='choice_1_14_2' id='label_1_14_2'>No</label> </li></ul></div></li><li id="field_1_15" class="gfield gfield--width-full field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_15"><label class='gfield_label gfield_label_before_complex' >How would you best describe yourself?</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_15'><li class='gchoice gchoice_1_15_1'> <input class='gfield-choice-input' name='input_15.1' type='checkbox' value='American Indian or Alaska Native' id='choice_1_15_1' /> <label for='choice_1_15_1' id='label_1_15_1'>American Indian or Alaska Native</label> </li><li class='gchoice gchoice_1_15_2'> <input class='gfield-choice-input' name='input_15.2' type='checkbox' value='Asian' id='choice_1_15_2' /> <label for='choice_1_15_2' id='label_1_15_2'>Asian</label> </li><li class='gchoice gchoice_1_15_3'> <input class='gfield-choice-input' name='input_15.3' type='checkbox' value='Black or African American' id='choice_1_15_3' /> <label for='choice_1_15_3' id='label_1_15_3'>Black or African American</label> </li><li class='gchoice gchoice_1_15_4'> <input class='gfield-choice-input' name='input_15.4' type='checkbox' value='Native Hawaiian or Other Pacific Islander' id='choice_1_15_4' /> <label for='choice_1_15_4' id='label_1_15_4'>Native Hawaiian or Other Pacific Islander</label> </li><li class='gchoice gchoice_1_15_5'> <input class='gfield-choice-input' name='input_15.5' type='checkbox' value='White' id='choice_1_15_5' /> <label for='choice_1_15_5' id='label_1_15_5'>White</label> </li><li class='gchoice gchoice_1_15_6'> <input class='gfield-choice-input' name='input_15.6' type='checkbox' value='Other' id='choice_1_15_6' /> <label for='choice_1_15_6' id='label_1_15_6'>Other</label> </li></ul></div></li><li id="field_1_21" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_21"><h2 class="gsection_title"></h2></li><li id="field_1_18" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_18"><label class='gfield_label gfield_label_before_complex' >Terms &amp; Conditions<span 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and conditions stated herein. All copyrights, trademarks, content, business methods, graphics, designs and documents posted on this website, as well as the look and feel of this website ("Intellectual Property") are the property of the Hope and Healing Center & Institute.<br /> <br /> The user may download one copy of the materials on any single computer and print a copy of the materials solely for use in learning about or utilizing Gateway to Hope's training materials and resources. The user may not otherwise copy, print, reproduce, distribute, transmit, upload, download, store, use, or change the materials. All such materials are copyrighted by the Hope and Healing Center & Institute.</div></li><li id="field_1_13" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_13"><h2 class="gsection_title"></h2></li><li id="field_1_9" class="gfield field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_1_9"><label class='gfield_label gfield_label_before_complex' >Newsletter Optin</label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_9'><li class='gchoice gchoice_1_9_1'> <input class='gfield-choice-input' name='input_9.1' type='checkbox' value='Please sign me up for updates, insights, resources, and more.' checked='checked' id='choice_1_9_1' /> <label for='choice_1_9_1' id='label_1_9_1'>Please sign me up for updates, insights, resources, and more.</label> </li></ul></div></li><li id="field_1_22" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_22"><label class='gfield_label' for='input_1_22' >Email</label><div class='ginput_container'><input name='input_22' id='input_1_22' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_1_22'>This field is for validation purposes and should be left unchanged.</div></li></ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' value='Submit' onclick='if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_1"]){return false;} if( !jQuery("#gform_1")[0].checkValidity || jQuery("#gform_1")[0].checkValidity()){window["gf_submitting_1"]=true;} jQuery("#gform_1").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='1' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_1' value='WyJ7XCIxOC4xXCI6XCI4ZWVjNjNkZDZhMDFjYjE5MjEyMzliY2M5YWNkNmNlMVwiLFwiMTguMlwiOlwiOTA2YWZlM2IyN2U5ZDFjYTQ4NmFkOGM4YmE3YWZlMzlcIixcIjE4LjNcIjpcImY4MGQwNTNlMzUwZjU5ZDM3M2M2YzJlZTc5ODViMzY2XCJ9IiwiZjI0MDg4NjhmY2IxNWYxMTZhN2QxYmJjNTk4YzAwNWYiXQ==' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='0' /> <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' /> <input type='hidden' name='gform_field_values' value='' /> </div> <input type="hidden" id="ct_checkjs_2291d2ec3b3048d1a6f86c2c4591b7e0" name="ct_checkjs" value="0" /><script type="text/javascript" >setTimeout(function(){var ct_input_name = "ct_checkjs_2291d2ec3b3048d1a6f86c2c4591b7e0";if (document.getElementById(ct_input_name) !== null) {var ct_input_value = document.getElementById(ct_input_name).value;document.getElementById(ct_input_name).value = document.getElementById(ct_input_name).value.replace(ct_input_value, 'daff13625f026def51775140059231ba46d5adca1056f439641605167e8402c2');}}, 1000);</script></form> </div>
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<div class='gf_browser_unknown gform_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_1' > <div class='gform_heading'> <h3 class="gform_title">EMPOWER Online Training Registration</h3> <span class='gform_description'></span> </div><form method='post' enctype='multipart/form-data' id='gform_1' action='/event/bipolar-disorder-co-occuring-substance-use-disorders/' novalidate> <div class='gform_body gform-body'><ul id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below'><li id="field_1_1" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_1"><label class='gfield_label gfield_label_before_complex' >Name<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_1_1'> <span id='input_1_1_3_container' class='name_first' > <input type='text' name='input_1.3' id='input_1_1_3' value='' aria-required='true' /> <label for='input_1_1_3' >First</label> </span> <span id='input_1_1_6_container' class='name_last' > <input type='text' name='input_1.6' id='input_1_1_6' value='' aria-required='true' /> <label for='input_1_1_6' >Last</label> </span> </div></li><li id="field_1_2" class="gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_2"><label class='gfield_label' for='input_1_2' >Email<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_email'> <input name='input_2' id='input_1_2' type='email' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_3" class="gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_3"><label class='gfield_label' for='input_1_3' >Phone<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_1_3' type='tel' value='' class='medium' aria-required="true" aria-invalid="false" /></div></li><li id="field_1_4" class="gfield gfield--width-full gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_4"><label class='gfield_label' for='input_1_4' >Company / Organization<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='medium' aria-required="true" aria-invalid="false" /> </div></li><li id="field_1_7" class="gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_7"><label class='gfield_label gfield_label_before_complex' >Password<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_complex ginput_container ginput_container_password' id='input_1_7_container'> <span id='input_1_7_1_container' class='ginput_left'> <span class='password_input_container'> <input type='password' name='input_7' id='input_1_7' value='' aria-required="true" aria-invalid="false" /> </span> <label for='input_1_7' >Enter Password</label> </span> <span id='input_1_7_2_container' class='ginput_right'> <span class='password_input_container'> <input type='password' name='input_7_2' id='input_1_7_2' value='' aria-required="true" aria-invalid="false" /> </span> <label for='input_1_7_2' >Confirm Password</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_19" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_19"><h2 class="gsection_title"></h2></li><li id="field_1_16" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_16"><label class='gfield_label gfield_label_before_complex' >Home Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_16' > <span class='ginput_full address_line_1 ginput_address_line_1' id='input_1_16_1_container' > <input type='text' name='input_16.1' id='input_1_16_1' value='' aria-required='true' /> <label for='input_1_16_1' id='input_1_16_1_label' >Street Address</label> </span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_1_16_2_container' > <input type='text' name='input_16.2' id='input_1_16_2' value='' aria-required='false' /> <label for='input_1_16_2' id='input_1_16_2_label' >Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city' id='input_1_16_3_container' > <input type='text' name='input_16.3' id='input_1_16_3' value='' aria-required='true' /> <label for='input_1_16_3' id='input_1_16_3_label' >City</label> </span><span class='ginput_right address_state ginput_address_state' id='input_1_16_4_container' > <input type='text' name='input_16.4' id='input_1_16_4' value='' aria-required='true' /> <label for='input_1_16_4' id='input_1_16_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip' id='input_1_16_5_container' > <input type='text' name='input_16.5' id='input_1_16_5' value='' aria-required='true' /> <label for='input_1_16_5' id='input_1_16_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country' id='input_1_16_6_container' > <select name='input_16.6' id='input_1_16_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Réunion' >Réunion</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option></select> <label for='input_1_16_6' id='input_1_16_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_17" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_17"><label class='gfield_label gfield_label_before_complex' >Work Address<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label> <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_1_17' > <span class='ginput_full address_line_1 ginput_address_line_1' id='input_1_17_1_container' > <input type='text' name='input_17.1' id='input_1_17_1' value='' aria-required='true' /> <label for='input_1_17_1' id='input_1_17_1_label' >Street Address</label> </span><span class='ginput_full address_line_2 ginput_address_line_2' id='input_1_17_2_container' > <input type='text' name='input_17.2' id='input_1_17_2' value='' aria-required='false' /> <label for='input_1_17_2' id='input_1_17_2_label' >Address Line 2</label> </span><span class='ginput_left address_city ginput_address_city' id='input_1_17_3_container' > <input type='text' name='input_17.3' id='input_1_17_3' value='' aria-required='true' /> <label for='input_1_17_3' id='input_1_17_3_label' >City</label> </span><span class='ginput_right address_state ginput_address_state' id='input_1_17_4_container' > <input type='text' name='input_17.4' id='input_1_17_4' value='' aria-required='true' /> <label for='input_1_17_4' id='input_1_17_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip ginput_address_zip' id='input_1_17_5_container' > <input type='text' name='input_17.5' id='input_1_17_5' value='' aria-required='true' /> <label for='input_1_17_5' id='input_1_17_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country ginput_address_country' id='input_1_17_6_container' > <select name='input_17.6' id='input_1_17_6' aria-required='true' ><option value='' ></option><option value='Afghanistan' >Afghanistan</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Réunion' >Réunion</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' selected='selected'>United States</option><option value='Uruguay' >Uruguay</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' >Zimbabwe</option><option value='Åland Islands' >Åland Islands</option></select> <label for='input_1_17_6' id='input_1_17_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li><li id="field_1_20" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_20"><h2 class="gsection_title"></h2></li><li id="field_1_14" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_14"><label class='gfield_label gfield_label_before_complex' >Are you of Hispanic/Latino/Spanish origin?<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_1_14'><li class='gchoice gchoice_1_14_1'> <input class='gfield-choice-input' name='input_14.1' type='checkbox' value='Yes' id='choice_1_14_1' /> <label for='choice_1_14_1' id='label_1_14_1'>Yes</label> </li><li class='gchoice 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id='label_1_15_2'>Asian</label> </li><li class='gchoice gchoice_1_15_3'> <input class='gfield-choice-input' name='input_15.3' type='checkbox' value='Black or African American' id='choice_1_15_3' /> <label for='choice_1_15_3' id='label_1_15_3'>Black or African American</label> </li><li class='gchoice gchoice_1_15_4'> <input class='gfield-choice-input' name='input_15.4' type='checkbox' value='Native Hawaiian or Other Pacific Islander' id='choice_1_15_4' /> <label for='choice_1_15_4' id='label_1_15_4'>Native Hawaiian or Other Pacific Islander</label> </li><li class='gchoice gchoice_1_15_5'> <input class='gfield-choice-input' name='input_15.5' type='checkbox' value='White' id='choice_1_15_5' /> <label for='choice_1_15_5' id='label_1_15_5'>White</label> </li><li class='gchoice gchoice_1_15_6'> <input class='gfield-choice-input' name='input_15.6' type='checkbox' value='Other' id='choice_1_15_6' /> <label for='choice_1_15_6' id='label_1_15_6'>Other</label> </li></ul></div></li><li id="field_1_21" class="gfield gsection field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_21"><h2 class="gsection_title"></h2></li><li id="field_1_18" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_1_18"><label class='gfield_label gfield_label_before_complex' >Terms &amp; Conditions<span class="gfield_required"><span class="gfield_required gfield_required_asterisk">*</span></span></label><div class='ginput_container ginput_container_consent'><input name='input_18.1' id='input_1_18_1' type='checkbox' value='1' aria-describedby="gfield_consent_description_1_18 gfield_description_1_18" aria-required="true" aria-invalid="false" /> <label class="gfield_consent_label" for='input_1_18_1' >I understand and acknowledge that by checking the box below, I am legally agreeing to all of the statements listed below.</label><input type='hidden' 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All copyrights, trademarks, content, business methods, graphics, designs and documents posted on this website, as well as the look and feel of this website ("Intellectual Property") are the property of the Hope and Healing Center & Institute.<br /> <br /> The user may download one copy of the materials on any single computer and print a copy of the materials solely for use in learning about or utilizing Gateway to Hope's training materials and resources. The user may not otherwise copy, print, reproduce, distribute, transmit, upload, download, store, use, or change the materials. 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