Workshop Registration Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders June 9, 2017 $150.00 Professional Rate $75.00 Student Rate (With copy of student ID) To REGISTER, please send this completed form to: Mail: Center for Anxiety and Related Disorders, ATTN: Shannon Sauer-Zavala 648 Beacon Street 6th Floor, Boston, MA 02215 Fax: 617-353-9609, ATTN: Shannon Sauer-Zavala is Limited. Please Register by June 2, 2017 Cancellation & Refund Policy: Fee $30 administration fee for all cancellations made five (5) business days prior to the event. No refund for cancellations made less than five (5) business days prior to the event. Last Name: First Name: M.I. Ethnicity Race: African Hispanic European Origin/White Telephone Number: Gender: Age: Non-Hispanic Asian Origin Female Male Native American Professional Affiliation: Profession E-mail Address: More Than One Race Other ___ @ __________ Payment Method: Card Type Name on Card Credit Card Visa AmEx Discover MasterCard (checks payable to CARD) Expiration Date Card Number Security Code Please provide additional information about your clinical experiences Your professional degree(s) related to psychotherapy: Fulfilled requirements for delivering psychotherapy as defined by your field (e.g., licensure, board certification): 1. 2. Yes No 3 Years of experience conducting psychotherapy (individual Years of experience conducting psychotherapy specifically or group): targeting anxiety disorders and depressive disorders: Which therapeutic orientations do you use in your treatment Please indicate the percentage of patients with whom you approach? Please check all that apply. use each of the following treatment elements: Psycho-education Cognitive Behavioral Self-Monitoring Psychodynamic Cognitive Restructuring Humanistic Situational Exposure Exercises Supportive Interoceptive Exposure Exercises Other Weekly Homework
Workshop Registration Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders June 9, 2017 $150.00 Professional Rate $75.00 Student Rate (With copy of student ID) To REGISTER, please send this completed form to: Mail: Center for Anxiety and Related Disorders, ATTN: Shannon Sauer-Zavala 648 Beacon Street 6th Floor, Boston, MA 02215 Fax: 617-353-9609, ATTN: Shannon Sauer-Zavala is Limited. Please Register by June 2, 2017 Cancellation & Refund Policy: Fee $30 administration fee for all cancellations made five (5) business days prior to the event. No refund for cancellations made less than five (5) business days prior to the event. Last Name: First Name: M.I. Ethnicity Race: Hispanic Non-Hispanic African European Origin/White Asian Origin Native American More Than One Race Other ___ __________ Telephone Number: Gender: Age: Female Male Professional Affiliation: Profession E-mail Address: @ Payment Method: Card Type Name on Card Credit Card (checks payable to CARD) Visa AmEx Discover MasterCard Expiration Date Card Number Security Code Please provide additional information about your clinical experiences Your professional degree(s) related to psychotherapy: Fulfilled requirements for delivering psychotherapy as defined by your field (e.g., licensure, board certification): 1. 2. 3 Yes No Years of experience conducting psychotherapy (individual or group): Years of experience conducting psychotherapy specifically targeting anxiety disorders and depressive disorders: Which therapeutic orientations do you use in your treatment approach? Please check all that apply. Please indicate the percentage of patients with whom you use each of the following treatment elements: Cognitive Behavioral Psychodynamic Humanistic Supportive Other Psycho-education Self-Monitoring Cognitive Restructuring Situational Exposure Exercises Interoceptive Exposure Exercises Weekly Homework
Registration%20Form-%206-2017.docx