WEBINAR EVALUATION FORM for CEUs Name First Last Date Date Format: MM slash DD slash YYYY PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website (if applicable) Your area of expertise, professional interests and focus:A. Based on the content of the course, I acquired knowledge of:1. The AAI Questionnaire*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree2. Attachment styles with emphasis on intimacy disorders.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree3. Protocols for treating insecure attachment.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree4. Examples of strategies that facilitate earned secure attachment.*Strongly AgreeAgreeNeutralDisagreeStrongly DisagreeB. Course Content and Learning Experience:1. Content was appropriate for LMFT, LCSW LPCC, and LEP training:*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree2. Information could be applied to my practice.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree3. Teaching methods were effective.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree4. Information was current and accurate.*Strongly AgreeAgreeNeutralDisagreeStrongly DisagreeC. Instructor, Dr. Mark Schwartz:1. Dr. Schwartz knew the subject matter.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree2. Dr. Schwartz presented the material well and answered questions effectively.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree3. Dr. Schwartz was responsive to questions that were posted or that were to be addressed in this presentation.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree4. Dr. Schwartz utilized course-appropriate technology to support learning.*Strongly AgreeAgreeNeutralDisagreeStrongly DisagreeD. Materials and Documents Provided1. Instructional materials were suitable and useful.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree2. Articles provided were of interest and relevant.*Strongly AgreeAgreeNeutralDisagreeStrongly Disagree3. The Hyperseuxal Behavior Inventory is a useful questionnaire for my practice and/or learning.*Strongly AgreeAgreeNeutralDisagreeStrongly DisagreeE. Open-ended QuestionsE-1. What was your overall impression of the course. What went well?*E-2. What could be improved? What suggestions might you have?*E-3. What topics and presenters would you like to see at future Harmony Place presentations?*E-4. Additional comments or requests:
