http:// www.counselcarecanadalearningsolutions.com Application Form for DBT-09180819 Comprehensive Program in Dialectical Behaviour Therapy September, 2018 Intake (Now Registering) Sept 24, 2018 to August 30, 2019 $2000 + HST: Early Bird Discount ($250) for registration and payment in full on or before July 10, 2018 Please complete this application form and return it to registration@ccclearningsolutions.com If you have any questions, please call: (519) 627-7655 or Fax (519) 627-7977, and allow 24 hours for a reply. In order to register for the Comprehensive Program in Dialectical Behaviour Therapy, participants are asked to: commit to participate fully in the program in the interest of their own learning and that of their learning peers; to use the DBT model as developed by Dr. Linehan and as taught in this program (fidelity to method); and to abide by the policy of respecting this curriculum as the sole property of, and not to be shared with others in any way without the explicit consent of this 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/City : Postal/Zip: Province/State: Telephone #: Time Zone: Email address: (please write clearly): Emergency Contact Name & Contact Information: 1
Professional Designation Registered Social Worker What is your Professional Discipline? Registered Social Service Worker Registered Psychologist Registered Nurse Addictions Counsellor Marriage & Family Therapist Registered Psychotherapist Mental Health Counsellor Occupational Therapist Registered Dietician Pastoral Counsellor/Priest Physician Pharmacist Recreation Therapist Other 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 DBT? ( 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 DBT? 2
Please check as many of the following that apply to your situation: I currently work with counselling/therapy clients on a regular basis (weekly) I currently have worked with counselling/therapy clients as a student: I have recently studied counselling but have never worked with a client: I have graduated from a counselling program and am in the process of setting up a practice: 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) Addictions Counselling (process addictions) Skills Training Educator of others in my discipline/other 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
In which of the following models (if any) 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 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 Basic Client Assessment Skills Case Conceptualization Setting Goals with Clients Providing Psycho-Education to Clients & Families Dealing with Emotional Dysregulation Non-Judgemental Acceptance of Clients Providing Feedback to Clients Staying on Track in Therapy Sessions Ending Client Therapy sessions on time Providing Homework to Clients Researching Client Diagnosis Seeking Supervision and Consultation When Required Formal Education & Supervision Informal Self- Directed Learning 4
Payment Information If Full Payment is Made Before July 10, 2018: Early Bird Cost Applies: ($1750 Plus HST = $1977.50) If Full Payment Made After July 10, 2018: (the Regular Cost Applies): ($2,000 HST = $2,260) When Payments Made in Three Equal Installments (a processing fee $55 applies). The Cost of $2,315, with three (3) Equal Payments of $771.66 If 3-payments are made, please note the time frame in which each payment will be due: 1 st payment of $771.66 (On or Before September 1, 2018) 2 nd payment of $771.66 (On or Before December 1, 2018) 3 rd payment of $771.66 (Before March 1, 2019) Check mailed 1 for amount of or Credit Card information (see below) # # # # # # # # # # # # # # # # # # # # # # # # # # ## # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # # Credit Card Information: MasterCard Visa American Express Discover Name as it appears on Credit Card (please print): Postal Code of Credit Card Owner: Credit Card Number #: Expiry Date: (month) year Three or Four Digit Security Code (on back of card in upper right corner): Postal Code: (See next page) 1 Check mailed to:, 707 James Street, Wallaceburg Ontario, Canada, N8A 2P4 5
I hereby authorize to charge my credit card account number and place my signature beside the payment option I have chosen and please initial in each blank space (of your option): Option # 1: A one-time payment for the total cost of the program (On or Before July 10, 2018 ) in the amount of $1977.50 Option # 2: A one-time payment for the total cost of the program (On or Before September 1, 2018) in the amount of $2260.00 Option # 3: Three payments can be made: 1 st payment of $771.66 (on or before September 1, 2018); 2 nd payment of $771.66 (on or before December 1, 2018); 3 rd payment of $771.66 (on or before March 1, 2019) Signature: 6