Workshop Registration

Name *

First

Last

Phone Number *

Email *

Level of Education *

License Number *

If you are an intern, please provide the license number of your supervisor.

Place of Employment *

If you are an intern, please provide your place of internship.

Name of Supervisor

First

Last

Interns ONLY

Graduate School Attended

Year of Graduation

I agree to the following: *

I understand that I will be participating in a training group and that I will not be receiving therapy during this group training experience.

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