Name: _______________________________________________________

Agency: _______________________________________________________

Address: ______________________________________________________


Postal Code: ___________________

Telephone: (____)___________________

Education: ____________________________________________________

Current Position and Duties: ____________________________________________________________


Related Experience: __________________________________________________________________


Current Supervisor: ____________________________________________

Telephone: (______)______________

Attach Work Sample : (Include one DISC Record Form with all identifying information deleted except for the child's age; all 3 Summary sheets; brief summary report re: child's history, observation during screening session, interpretation of results, referrals or programming strategies.) Please also include a video of the administration of the DISC corresponding to your work sample along with a video critique. A Report Outline for the DISC and Video Critique form are available on the DISC website.

Total # of DISC Screenings Completed to Date: ______ A minimum of 25 DISC administrations is advised before submitting a Level III work sample.

Have you attended a Level III DISC Training Workshop? No: ___ Yes: ___

Date: ____________

If No, please enclose a cheque for ($50. + $6.50 HST) $56.50 for marking.

Please return this application and work sample to: Marian Mainland

Mainland Consulting Inc. 4 Danube Drive,
Heidelberg, Ontario
NOB 1YO, Canada
Phone: (519) 699-5429 Fax: (519) 699-4890

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