Brainspotting Phase 1 Registration Form Phase 1 Registration and Payment Form Name * Name First First Last Last Email where you will receive all communications and zoom link: * Best Contact Phone Number before and during the training (include country code if outside the USA): * Profession and Professional Licensing Information: * Full Physical Address you will be located during the training (including country, province, state, and zip code): * Full Mailing Address if Different from Location or you can put “Same”: * Emergency Contact Name and Relationship to You: * Emergency Contact Phone Number (include country code): * During the training there will be practicum in dyads to practice the Brainspotting Set Ups in breakout rooms. Do you have any requests regarding who you are partnered? You do not have to partner with the same person each practicum. These requests will be met to the best of our ability. * Would you like to participate as a volunteer during the demonstrations? This involves engaging with the trainer to illustrate the Brainspotting set ups using a perinatal experience. The demo will be recorded and the participants will observe the demonstration live. This is optional and voluntary and the selection is based on best fit to illustrate the set up, not the content of the lived experience. Yes I agree to have Supportive Solutions, LLC use my email contact to advise me of any further trainings or opportunities offered. * Yes No I have read and accept Supportive Solutions, LLC Training: Policies and Guidelines of Participation in this Phase 1 Brainspotting Training and agree to the policies and cancellation policy. * Yes No Do you have any comments or information we should know in advance to the training? * Standard Registration Rate (July 12-August 28, 2022) Rate: $795 USD Standard Registration Rate plus $25 for CEs (July 12-August 28, 2022) Rate: $795 plus $25 CEs USD Canada Residents and Clinicians who work with Marginalized Communities $550 Rate: $550 USD Canada Residents and Clinicians who work with Marginalized Communities and Continuing Education (CEs) $575 Training $550 plus $25 CEs Professional re-taking the same Phase training attended previously in a live format OR Full-Time Students in an accredited program $400 -Professional re-taking the same Phase training attended previously in a live format -Full-Time Students in an accredited program $400 Professional re-taking the same Phase training attended previously in a live format OR Full-Time Students in an accredited program and Continuing Education (CEs) $425 -Professional re-taking the same Phase training attended previously in a live format -Full-Time Students in an accredited program $400 plus $25 CEs Total If you are human, leave this field blank. Proceed to Payment
