Fourteenth Statewide Conference on
Co-Occurring Disorders

Integrating Substance Use, Mental Health, and Primary Care Services in Our Communities:

"Resilience in a Changing Environment"

Hilton Universal City Hotel at Universal City

555 Universal Hollywood Drive • Universal City, CA 91608

October 25-26, 2017

Please fill-in the registration information below.
Upon completion you'll be forwarded to our secure credit card payment form.

Helpful Hints:

  1. If you are registering more than one person with a single credit card, please fill out a separate registration form and make a credit card payment for each person.
  2. If you register online, there is no need to fax or mail any additional paperwork to UCLA ISAP. Your registration will be confirmed upon receipt of payment.
  3. If you have any trouble using the online registration system, please contact Shannon Bertea at (310) 267-5398 for immediate assistance.

Fields with * must be filled-in.

*First Name: First name is required.
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*Continuing Education Credits

Please select all that apply:

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If "Other", please specify:

   
If not licensed or certified, please type, "None" in the box:

License/Certification No.:
Please provide your license or certification number or indicate "None".


Special Requirements

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American Sign Language Interpreter
ADA accessibility
Vegetarian

Other (Please specify):


How Did You Hear About Us?

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Printed Flyer
Email/Website
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Ad in "The Fight" Magazine

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*Sessions and Workshops

Please specify the workshop you
plan to attend for each session:

For workshop details, click here to download conference brochure.

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Day 1, Session I

Day 1, Session II

Day 2, Session III


*Please Specify Your Primary Employment Setting:

Please check one:

Primary Care
Mental Health
Substance Use
Other

Other (Please specify):


Standard Registration Fee: $125 (same fee for one or both days)


DMH Registration Fee: $60 (same fee for one or both days)

Los Angeles Department of Mental Health Employees ONLY.
Please enter your 6-digit LACDMH employee number:

Program/Unit:

Please provide the information requested below.
Your supervisor's name:
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Exhibit Tables

Exhibitor space is limited. Please contact Shannon Bertea at sbertea@mednet.ucla.edu with any questions.

$600 - Exhibit Table

 

Exhibitor space at the conference is sold out. Please contact Shannon Bertea at sbertea@mednet.ucla.edu with any questions.


Total Amount Due:

Please click the "Submit Registration Information" button ONLY ONCE.