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1 Comprehensive Certificate Program in Cognitive Behaviour Therapy for Registered Nurses Application Form for CBT-CC/RN September 26, 2016 to January 27, 2018 Registration Deadline August 5, 2016 Early Bird Discount of $200 Available Until July 15, 2016 Please complete this application form and return it to If you have any questions, please call: (519) or Fax (519) , and allow 24 hours for a reply. In order to register for the CounselCareCanada Learning course Comprehensive Certificate Program in Cognitive Behaviour Therapy for Registered Nurses, participants are asked to commit to: participate fully in the program in the best interest of themselves and their learning peers; to use the CBT model to its fullest as taught in this program (fidelity to method); and to abide by the policy of respecting the curriculum for the course Comprehensive Certificate Program in Cognitive Behaviour Therapy for Registered Nurses, as the sole property of, and not to share with others in any way without the explicit consent of the organization. I agree to the conditions listed above. Personal Information (please complete all fields) First Name: Middle Name/Initial: Last Name: Male: Female: Street Address: (number & name): Town or City Name: Postal/Zip: Province/State: Telephone #: Time Zone: address: (please write clearly): Emergency Contact Name & Contact Information: 1

2 Professional Experience Are you a student in your field? (If so please indicate the name of your program and school): How many years have you worked in your discipline? What is your current knowledge level in CBT? (Read a book, it was covered in a course, attended a workshop, none, etc.): Do you have access to clients with which you can practice CBT? Please check as many of the following that apply to your situation: I currently work with or have worked with mental health clients on a regular basis I currently work with or have worked with mental Health clients as a student: I have recently studied Mental Health but have never worked with a client: 2

3 Please check the services you have provided to counselling/therapy clients: Service Supervision of others in my discipline Individual Psychotherapy Group Psychotherapy Addictions Counselling (substance) Addictions Counselling (process) Skills Training Educator of others in my discipline As a student counsellor/therapist Crisis Intervention Role Community Treatment of Severe Mentally ill Case Management in the Mental Health Field Group Psychoeducation Pharmacotherapy Support to Family Members At Risk Clients Past (# of years) Current 3

4 In which of the following models have you received training and supervision? Name of Model Client Centered Therapy Contextual Therapy Brief Solutions Focused Therapy Gestalt Therapy Object Relations/ Self-psychology Therapy Integrative Therapy Expressive (Narrative) Analytical Systems Therapy Mindfulness Models Schema Based Therapy Insight Oriented Therapy Play Therapy Nursing Theories Formal Course Based Supervision Self-Directed Learning Please indicate the Methods/Techniques you already use in your practice, and how these methods/techniques were learned: Methods/techniques Cognitive Behaviour Therapy (Assessment) Cognitive Behaviour Therapy (Individual Case Conceptualization) Collaboratively Setting Therapy Goals with Clients Psycho-Education about Thoughts, Beliefs, and Actions Radical Acceptance of Clients Cognitive Interventions for Schema Change Identification and Evaluation of Negative Automatic Thoughts (NATS) Identification of Emotional Dysregulation in Clients Providing Insight into Client Problems Increasing Self-cohesion and Integration Client Skills Training Formal Education & Supervision Informal Self- Directed Learning 4

5 Payment Information A deposit of $500 is required on registration, and will be deducted from the total cost of the program (in the form of a credit card payment or check made payable to ) The Early Bird Discount of $200 is offered to those who Register and pay in full before July 15, 2016 Program Cost (due with application): In form of check made payable to or with Credit Card. Credit Card information sent or Check mailed 1 for amount of (Cost of Program and 13% HST) (Before Aug 8, 2016: $2975 Less Early Bird Discount of $ = $2775 plus HST $ = $ ) (After Early Bird Date: $2975 plus HST, $386.75= $ ) It is possible to make two payments ($25 fee for processing: Total, $ ) 1 st payment of $ (before September 29) 2 nd payment of $ (before January 30) 3 rd Payment of $ ((before May 30 with $500 deposit deducted) Credit Card Information: MasterCard Visa American Express Discover Name as it appears on Credit Card (please print): Address of Credit Card owner (if different than above): Credit Card Number #: Expiry Date: (month) year Postal Code of Credit Card owner: Three or Four Digit Security Code, depending on Credit Card Company, (on back of card in upper right corner): Signature: (Please see next page) 1 Check mailed to:, 707 James Street, Wallaceburg Ontario, Canada, N8A 2P4 5

6 I hereby authorize to charge my credit card account number and hereby place my signature beside the payment option I have chosen: 1. A one-time payment for the total cost of the program now (before July 15) in the amount of $ A one-time payment for the total cost of the program (after July 15 but before Aug 5) in the amount of $ (When a Payment Plan is scheduled, a one-time processing fee of $25 is charged and the total is $ ) 3. The Deposit Fee only now in the amount of $500 ; the 1st Payment to be charged to my account (before September 26) in the amount of $ ; the 2nd payment to be charged to my account before January 30 in the amount of $ the 3rd payment to be charged to my account before May 30 in the amount of $628.92(deposit applied) 4. The Deposit Fee and the 1st Payment (after July 15 and before Aug 5) in the amount of $ ; the 2nd payment to be charged to my account on January 30 the amount of $ : the 3rd payment to be charged to my account on May 30 the amount of $ Signature: 6