New York Registration Form 2015-2

Your registration for the Trial-Based Cognitive Therapy (TBCT) workshops will be confirmed after payment to Irismar Reis de Oliveira, on behalf of the Trial-Based Cognitive Therapy Institute (Address: 6574 E Brainerd Rd Apt 211, Chattanooga, TN 37421-3702). For instructions regarding payment, please, send an e-mail to irismar.oliveira@uol.com.br.

WS 1 (November 20-21, 2015): Restructuring Automatic Thoughts with TBCT Techniques ($400) - 16 CEs*
WS 2 (January 22-23, 2016): Restructuring Underlying Assumptions and Core Beliefs with TBCT Techniques ($400) - 16 CEs*
WS 3 (March 11-12, 2016): Restructuring Core Beliefs and Enhancing Metacognitive Awareness with TBCT Techniques ($400) - 16 CEs*
WS 1 + WS 2 = $700 (you save $100) - 32 CEs*
WS 2 + WS 3 = $700 (you save $100) - 32 CEs*
WS 1 + WS 2 + WS 3 = $900 (you save $300) - 48 CEs*
*CEs are not included in the above fees. TBCT Institute is now approved to provide CEs to social workers in New York.

For those who desire extra-class supervision, supervisors (Donna Sudak and Noah Clyman) will be available for weekly or biweekly supervision; however, this is not included in the above mentioned fee.

The earlier you register, the sooner you guarantee your participation.

Please, send an e-mail to Irismar de Oliveira (irismar.oliveira@uol.com.br) if you have further questions.

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1. Please provide the information below:

Full name: *

Where you work/study: *

Address 1: *

Address 2 (optional):

City: *

State: *

Zip code:

Country:

Email Address: *

Phone Number: *

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2. I'm signing up to attend:

WS 1: Restructuring Automatic Thoughts with TBCT Techniques, and will pay $400

WS 2: Restructuring Underlying Assumptions and Core Beliefs with TBCT Techniques, and will pay $400

WS 3: Restructuring Core Beliefs and Enhancing Metacognitive Awareness with TBCT Techniques, and will pay $400

WS 1 + WS 2 and will pay $700 (I save $100)

WS 2 + WS 3 and will pay $700 (I save $100)

WS 1 + WS 2 + WS 3 and will pay $900 (I save $300)

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3. Background:

Psychologist

Psychiatrist

Social worker

Counselor

Psychiatry resident

PhD student

ACT fellow/diplomate

Other

If you marked "other," please, specify:

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4. I will need CEs:

Yes (In this case, I will pay an additional $50 for each certificate needed)

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5. Describe your experience as a therapist. This information will help us adapt the content to the participants average experience.

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6. Please, list the last 3 psychotherapy books you have read.

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7. Attendance of the TBCT workshops does not guarantee certification in TBCT. By clicking "I agree," I understand that certification is dependent on the following criteria:*
1) the techniques that will be taught will be used in at least one patient/client during the training;
2) demonstration of competency using all the techniques taught during the training, as shown in role-plays (competency will be evaluated by the facilitator and/or co-facilitator);
3) having a current valid license to do psychotherapy in the region (i.e. state, country) I live;

*Trainees who do not reach competency during the term will receive a Letter of Participation and may enroll in additional terms.

I agree