Registration - Supportive Solutions

Brainspotting to Heal Perinatal Trauma Training Registration Form

First and Last Name *

Email *

Please use same email address you will use to register for the Zoom meeting

Phone *

Best contact phone number before and during training

Are you Registering for Day 1 or Both Days of Training? *

Registering for Day 1 ONLY October 24, 2022 9:00am to 5:00pm Eastern Time USA (I am not yet Phase 1 Brainspotting trained or only plan to attend this day)|$280.00

Day 1 ONLY plus Continuing Education (CEs)|$305.00

I AM BRAINSPOTTING PHASE 1 Trained: Registering for Day 1 and Day 2, Monday October 24 and Tuesday October 25, 2022 9:00am to 5:00pm Eastern Time USA |$560.00

Registering for Day 1 and Day 2, plus Continuing Education (CE's)|$585.00

If Registering for Both Days, Who was your Phase 1 Trainer, was it live or online and what month and year did you take the training? If you have completed Phase 2, share your trainer and month and year taken. *

Profession and Professional Licensing Information *

Full Physical Address you will be located during the training *

Full Physical Address you will be located during the training

City

State/Province

Zip/Postal

Country

Emergency Contact Name and Relationship to You *

Emergency Contact Phone Number *

Please include country code.

What topics would you like covered in the training or what question do you hope is answered? *

I agree to have Supportive Solutions LLC use my email contact to advise me of any further training and electronic communications they are offering. *

Yes

I have read and accept Supportive Solutions, LLC Training: Policies and Guidelines of participation in this training of Brainspotting to Heal Perinatal Trauma *

Yes

On clicking "Submit," you will be redirected to Paypal, where you can pay with a Paypal account or as a Guest by using Debit/Credit Card by selecting the "Pay with Debit or Credit Card" button on the bottom of the screen.

If you are human, leave this field blank.