Houston Registration Form
(Offered both face-to-face and live online)

Your registration for the Trial-Based Cognitive Therapy (TBCT) training* will be confirmed after payment to Irismar Reis de Oliveira via PayPal using the e-mail address irismar.oliveira@uol.com.br. Please, see instructions here: https://www.youtube.com/watch?v=yIiWoA35sxI

Please, send an e-mail to Irismar de Oliveira (contact@trial-basedcognitivetherapy.com) if you have further questions.

Part 1 (April 6-7, 2018): Treatment of depression with TBCT

Part 2 (May 4-5, 2018): Treatment of anxiety disorders with TBCT

Part 3 (June 1-2, 2018): Treatment of personality disorders with TBCT*

*Part 3 will be offered ONLINE ONLY.

Question Title

* 1. I will attend:

the face-to-face format

the live online format only

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* 2. Please provide the information below:

Full Name: *

Where you work/study: *

Address 1: *

Address 2 (optional):

City: *

State: *

Zip code:

E-mail address:

Confirm e-mail Address: *

Phone Number: *

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* 3. I am signing-up to attend

Workshop 1 (two days) and will pay $300

Workshop 2 (two days) and will pay $300

Workshops 1 and 2 (four days) and will pay $550

Workshops 2 and 3 (four days) and will pay $550

Workshops 1, 2 and 3 (six days) and will pay $700

I am a student (see payment options below)

I am a New Dimensions member (see payment options below)

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* 4. If you are a student or a New Dimensions member, please, indicate your choice below:

Workshop 1 (two days) and will pay $200

Workshop 2 (two days) and will pay $200

Workshop 3 (two days) and will pay $200

Workshops 1 and 2 (four days) and will pay $400

Workshops 2 and 3 (four days) and will pay $400

Workshops 1, 2 and 3 (six days) and will pay $600

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* 5. Background:

Psychologist

Psychiatrist

Social worker

Counselor

Marriage and family therapist

Chemical dependency counselor

Other

If you marked "other," please, specify:

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* 6. I will need CEs:

Yes

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

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* 8. In order to sign-up to attend this training, I am aware that participants must be licensed or have a limited permit as a psychologist, social worker, mental health counselor, psychiatrist, psychiatric nurse, or nurse practitioner, LMFT, or they must be currently enrolled in a licensure-qualifying graduate program.

I agree

I do not agree (In this case, please, do not sign-up)