We have included this online form to make registering for the 2006 Intensive quick and easy...

2006 DBT Intensive Course

Online Registration

Register for 2-day Workshops CLICK HERE

Mental Health Australia has included this online form to make applying for the 2006 DBT Intensive Training Course quick and easy.

One of our staff will contact you within 5 days of receiving your application.

COURSE LOCATION & DATES

Melbourne 16-20 April 2007 (Part 1) and October 22-26

Presenters: Kate Comtois PhD and Robin McCann PhD

I would also like to purchase the following DBT Resources (Prices Inc GST and Postage)

Do you have any special dietary needs? (Vegetarian, Diabetic...)

How did your hear about the MHA Intensive DBT Training Course?

   PART A -TEAM INFORMATION

   Team Name/ Institution Affiliation:

    Team Leader/Contact Person:

     Team Leader/Contact Person's Details

    Address:



    Work Telephone:                Home Telephone:

    Fax:                       Email:



     Other team members applying for Course:









     Nature of team and length of time together:



     Do you have any plans to evaluate or conduct research on DBT? Please describe.

   PART B - INDIVIDUAL INFORMATION

   Name

Address:



    Work Telephone:                Home Telephone:

    Fax:                       Email:



    Occupation:

    Your highest degree: Year:

    Major area of study:

    Professional Membership(s):

    Registrations (States & Country): For Example Psychologists, VIC, AUSTRALIA Reg No. 121215454

    Type of clinical experience (check all that apply):

          Individual psychotherapy             Crisis intervention               Group psychotherapy

          Inpatient          Pharmacotherapy         Outpatient           Case Management

    Type of contact with clients meeting criteria for BPD:

Training in DBT (check all that apply):

Read Dr. Linehan�s articles/book chapters

Read Dr. Linehan�s treatment manual (All participants must read before coming)

Read Dr. Linehan�s skills training manual (All participants must read before coming)

Attended a DBT study group

Attended a workshop (please tick: 1/2 day, 1 day, or 2 days)

Attended DBT consultation(s) (please describe):

Received DBT supervision (please describe):

Participated in DBT therapy (please describe):

Describe background in Behaviour Therapy (e.g., readings, training, other experience):

Describe background in therapies focusing on client-therapist relationship issues (e.g., transference and counter-transference in psychodynamic therapies):

Describe background in meditation or "mindfulness" (e.g., readings, training, other experience):

To what extent do you regularly use techniques in your therapeutic work, which are also found in DBT (e.g., behavioural principles of reinforcement, explicit contingency schedules, exposure, etc.)? Describe the techniques you use most.

Describe which DBT principles or techniques you are least well versed in.

List one or two specific expectations you have for yourself in this workshop.

PAYMENT OPTIONS

Payment Frequency

OPTION 1 Send my invoice to my organisation using the payment frequency stated above:

Name of Payer Contact:

Name of Payer:

Address:

Telephone: Fax:

Email:

OPTION 2 Please charge my credit card using the payment frequency stated plus 3%:

(Bankcard, MasterCard or Visa - please add 3% to course fee)

Credit Card Details

Name on Card

Credit Card Type Card Number

Card Expiry Date /

OPTION 3 I wish to pay offline using the payment frequency stated above:

By Cheque - Mail completed registration form and payment to:
MENTAL HEALTH AUSTRALIA: PO Box 445 St.Kilda VIC 3182

By Credit Card (Bankcard, MasterCard or Visa - please add 3% to course fee) We will need your CARD

    NUMBER, NAME, EXPIRY DATE & SIGNATURE
          � Mail details to Mental Health Australia Pty Ltd, PO Box 445 St.Kilda VIC 3182
          � Fax details to (03) 9527 8194
          � Email details to peterk@dbtworkshops.com
          � Call in details to (03) 9528 8444

PAYMENT

Terms and Conditions

Requests for refunds must be made in writing. Full refund, minus a $199.00 service charge, will be made for requests postmarked 90 days prior to the beginning of the course. No refunds will be made thereafter.

The application fee is $99.00 for each individual team member. Application fees are non-refundable and are not a credit towards the tuition. Applications without application fees will not be considered.

Submission of an application does not guarantee a place in the DBT Intensive Training Course.   Applicants must meet the course criteria and will be accepted into the course on a first come first in basis. Teams of 4 or more need only apply.

The DBT Intensive training course is for 64 participants

I acknowledge the terms regarding the terms and conditions of this application

     Sub-total A (Course Application Fee)
     Sub-total B (Course Payment)
     Sub-total C (Pre-course resources)

                                             TOTAL:

Further Information or comments

Complete application form and forward payment to secure your place in the DBT Intensive Course.

Applications for the Intensive Training are due by Friday February 23rd 2007

MENTAL HEALTH AUSTRALIA: PO Box 445 St.Kilda VIC 3182 - Tel: 03 9528 8444 Fax: 03 9527 8194 Email: peterk@dbtworkshops.com

Updated: Friday, 03 November 2006