Registration Form

Practicing Self-Compassion with Psychodrama:

A 2-Day Workshop for Personal Growth and Professional Development

Sylvia Israel, LMFT, RDT/BCT, TEP

Registration Form

October 8-9, 2022

Thank you for your interest in participating in the Workshop.

To finalize your registration and hold your space:

1. Complete this Registration Form. Be sure to indicate your method of payment.

2. Read and sign the Informed Consent & Release Form and the Covid Waiver for In-Person Events Form.

3. Please submit the following forms and payment as soon as possible or within a week of receipt.

Send to Sylvia Israel at sylvia@imaginecenter.net:

a.  Registration Form

b.  Signed Informed Consent & Release

c. Signed Covid Waiver for In-Person Event

d. Submit payment as directed below.

Note: All forms can be filled out on your computer.

If needed, cut and paste into an email.

If you have trouble, print and scan, or mail to:

Sylvia Israel. 815 Bolinas Road. Fairfax, CA 94930.

Contact Sylvia with any questions: Sylvia@imaginecenter.net; or after 9/17/22 call

415-454-7308.   

You may type directly on this form and save it with your name.

Name:

Address:

Phone (include home, work, cell and indicate which is best to use):

Email:

Emergency Contact (name, relationship, phone number(s)):

Place(s) of Employment:

EDUCATIONAL & PROFESSIONAL BACKGROUND

Highest Degree:

Discipline/Field of Study:

Licensure/Certification (include license number is applicable):

Previous Training/Experience with Psychodrama. Include approximate hours of psychodrama training and names of trainers:

Previous Training in Other Experiential Approaches:

Experience Working with Clients (Include approximate number of years and populations):

CURRENT INTERESTS AND AREAS OF STUDY

What currently excites you? What are you reading, studying, doing, experiencing that has captured your interest?

LEARNING GOALS AND EXPECTATIONS

In what settings are you currently or do you plan to apply the concepts and skills you acquire in the workshop/training?

What are two strengths/resources you bring to the workshop/training?

What do you consider your two biggest challenges or growing edges as a student of psychodrama or participant in this workshop/training?

What is one specific professional and/or one specific personal goal/intention you will set for this workshop/training experience?

Professional:

Personal:

Is there anything else you would like me to know about your interests, preferences, and/or needs for this workshop/training experience?

PAYMENT INFORMATION

FEE: $360 by 9/25/22; $400 after. Students (with full-time ID): $285.

Full refund up to two weeks prior to first day. 50% one week prior. No refund thereafter.

Payment plans available. Please inquire.

________I am a licensed psychotherapist and would like to receive 20 CEUs.

Name (as written on License) and License number:

Additional Fee: $25.00

Payment by check to: Sylvia Israel. 815 Bolinas Road. Fairfax, CA 94930.

Zelle or Venmo: Sylvia Israel sylvia@imaginecenter.net (415) 686-6800

Please let Sylvia know if you need a payment plan.

My method of payment:                

Venmo________

Zelle__________

Check_________

Date I made electronic payment or mailed check: _______