New York Registration Form 8th edition

Your registration for the Trial-Based Cognitive Therapy (TBCT) training in New York 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 contact@trial-basedcognitivetherapy.com.

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

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1. I am signing up to attend:

Part 1 (Sep 18-19, 2016): Restructuring Automatic Thoughts with TBCT Techniques, and will pay $400

Part 2 (Oct 30-31, 2016): Restructuring Underlying Assumptions and Core Beliefs with TBCT Techniques, and will pay $400

Part 3 (Feb 17-18, 2017): Restructuring Core Beliefs and Enhancing Metacognitive Awareness with TBCT Techniques, and will pay $400

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

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

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

As a guest

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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:

Country:

Email Address: *

Phone Number: *

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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 fee for each certificate to R. Cassidy Seminars)

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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. 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)