Legal Disclaimer: The views
and opinions contained in the
educational offerings described
in this publication do not
necessarily reflect those of the
Division of Mental Health and
SubstanceAbuse or the Department of Health and Social Services, and should not be construed as such. 
LEARNINGCONTRACT

PLEASE PRINT 
LAST NAME FIRST NAME 
BUSINESS /AGENCYADDRESS 
CITY  STATE  ZIP CODE  
(  )  (  )  
HOME PHONE  BUSINESS PHONE  

E­MAILADDRESS 
DISABLED (CHECK ONE) GENDER (CHECK ONE)
.YES .NO .M .F

HIGHEST DEGREE COMPLETED (CIRCLE ONE)
HS GED AA LPN RN BA/S MA/S MSW PH/MD

I WILLBEAPPLYINGFOR CEU’S WITH: 
(SEE THE CERTIFICATION SECTION OF THE DSAMH TRAINING CATA­LOG FOR DETAILS) 
.CEAP .DBN .DCB .DPA
.NAADAC.NCC .NCGC

AGENCY
Agency Code: Agency Name:
(see back of this form for list of agency codes)


POSITION: PLEASE CHECK THE ONE THAT BEST DESCRIBESYOU: 
. Administrator/Manager . Physician
. Aide/Outreach . Prevention Worker
. Case Manager/Counselor/Therapist . Psychologist
. Chaplain/Ministry . Social Worker
. Consultant . Student
. Consumer . Supervisor (clinical)
. Educator/Teacher/Instructor . Support Staff
. EmployeeAssistant Personnel . Volunteer
. Nurse . Other

ETHNICITY: (CIRCLE ONE)
AlaskanNative AsianAmerican AfricanAmerican Caucasian
Hispanic NativeAmerican PacificIslander Other ____________

PLEASE COMPLETEALLREQUESTED INFORMATION TO ENSURE PROCESSINGAND REGISTRATION 
WORKSHOPS REQUESTED 
1) WORKSHOPNUMBER DATE 
LOCATION 
WORKSHOPTITLE How do you meet the prerequisite? (if applicable) 
2) WORKSHOPNUMBER DATE 
LOCATION 
WORKSHOPTITLE How do you meet the prerequisite? (if applicable) 
3) 
WORKSHOPNUMBER DATE 
LOCATION 
WORKSHOPTITLE How do you meet the prerequisite? (if applicable) 
I understand that I should receive a confirmation of admissiontoaworkshopbeforeIattend. IFIAMNOT ABLE to attend a workshop, I will notify the Training Office at least 4 days in advance. I understand that all NO­SHOWS (someone who was admitted into a workshop, did not attend, and did not alert the Training Office) will be reported to my Program Director on a monthly basis. 
APPLICANT SIGNATURE DATE 
SUPERVISOR SIGNATURE (REQUIRED) DATE 
SUPERVISOR FULLNAME (PRINT ONLY) 
SUPERVISOR E­MAIL 
ALLREQUESTED SIGNATURESARE REQUIRED FOR PROCESSINGAND REGISTRATION 
HAVE QUESTIONS? 
Mail or FAX the completed Learning Contract to: For further information, call (302) 255­9480 DSAMH Training Office or e­mail us at DSAMH.training@state.de.us Springer Building, 1901 N. Dupont Highway 
New Castle, DE 19720 Fax: (302) 255­4450 

AA. Aquila of Delaware, Inc. 
AB. Brandywine Community Resource Council, Inc. 
AC. Brandywine Counseling 
AD. Carelink Community Support Services 
AE. Central Delaware Committee on Drug &AlcoholAbuse 
AF. Christiana Care Health Services 
AG. Community Mental Health Centers 
AH. Connections 
AI. Delaware Council on Gambling Problems 
AJ. Delaware Psychiatric Center 
AK. Delmarva Rural Ministries 
AL. Dover Behavioral Health 
AM. DSAMH Central Office 
AN. Fellowship Health Resources 
AO. Gateway Foundation 
AP. Gaudenzia, Inc. 
AQ. Horizon Healthcare of Delaware 
AR. Horizon House of Delaware 
AS. Hudson Health Services 
AT. K/S Detox Center 
AU. Kent County Counseling 
AV. La Red Health Center 
AW. LatinAmericanCommunityCenter 
AX. Limen House 
AY. MentalHealthAssociation 
AZ. MLK Center 
BA. National Alliance for the Mentally Ill of Delaware (NAMI­DE) 
BB. NET (Delaware), Inc. 
BC. OPEI (Office of Prevention and Early Intervention) 
BD. Psychotherapeutic Services, Inc. 
BE. Resources for Human Development 
BF. Serenity Place 
BG. SODAT 
BH. Sussex County Counseling 
BI. TreatmentAccessCenters 
BJ. Thresholds, Inc. 
BK. Universal Health Services 
BL. Westside Health 
BM. WhatcoatSocialServicesAgency,Inc. 
BN. Other