Registration Form FOR THE REGIONAL TRAINING SERIES FALL 2009

Please duplicate this registration form as needed

PLEASE NOTE:  Pre-registration is REQUIRED

Telephone registrations CANNOT be accepted.      

Please register TWO WEEKS BEFORE THE COURSE(S)

YOU WISH TO ATTEND as space may be limited.

Please MAIL  or  FAX this registration form to:

WPIC OERP, Attention:  Nancy Mundy

3811 O’Hara Street, 4601 Baum Building, 1st Floor

Pittsburgh, PA  15213

FAX:  (412) 802-6910

only continuing education credits listed on the individual program DESCRIPTION ARE available for that program.                                            

Registration forms and information on our upcoming programs are available on the WPIC/OERP website at: http://www.wpic.pitt.edu/oerp

Social Security# (last 5 digits):

FOR CONTINUING EDUCATION PURPOSES, PLEASE INDICATE YOUR CERTIFICATION NEEDS:

Name (Last, First):

Agency:

q  NBCC

        COUNSELOR

 

q  PCHA

Address: 

 

q  NURSE

 

q  CAC/CCDP COUNSELOR

City:

 

q  CPRP

 

q  ACT 48

ID#_______________

State:

Zip Code:

 

q  SW/LPC/LMFT

County:

 

 

q  Psychologist

Day Telephone:  (           )

 

Are you a WPIC employee?      □ yes         □ no

 

Email:

Please indicate with an X which program(s) you wish to attend:

 

 

 

WPIC/UPMC Tuition

 

 

MC09

$80

$50

Best Practices in the Assessment and Treatment of Oppositional Defiant Disorder, 9/17/09, UPMC Shadyside, West Wing Auditorium

 

MC07

$80

$50

Best Practice Supports for Individuals with Autism Spectrum Disorder Across the Lifespan, 9/30/09, Pressley Ridge

 

MC12

$80

$50

Basic Group Counseling for Dual Disorders, 10/02/09, UPMC Shadyside, Cooper Conference Center

 

MC00

$80

$50

Ethics and Addiction, 10/15/09, UPMC Shadyside, Herberman Conference Center

Select breakout session:  ____ A. Co-occurring Disorders    ____ B.  The Best of Intentions:  When Addiction Ethics and the Law Clash  ____ C. Ethics, Addiction and the Medical Patient

 

MC05

$80

$50

Cognitive-Behavioral Treatment (CBT) of Obsessive Compulsive Disorder (OCD):  The “How To’s” of CBT and Exposure with Response Prevention (ERP) , 10/21/09, UPMC Horizon, Greenville Campus

 

MC06

$80

$50

Life Skills Training Program based on Dialectical Behavior Therapy with a focus on Mindfulness, 10/30/09, Northco, RIDC Park

 

MC08

$80

$50

Early Childhood Treatment Programs, 11/06/09, Community Counseling Center, Hermitage, PA

 

MC11

$80

$50

An Overview of Behavioral Health Diagnoses in Older Adults and Current Treatment Strategies, 11/11/09, California University of PA

 

MC13

$80

$50

Advanced Group Counseling for Addiction or Co-Occurring Disorders, 11/19/09, UPMC Shadyside, Herberman Conference Center

 

MC14

$80

$50

Cognitive Behavior Therapy – Best Practice Approaches in Conducting CBT Groups for Adults, 11/20/09, UPMC Shadyside, Cooper Conference Center

 

MC01

$80

$50

Hypnotherapy for Anxiety and Pain, 12/01/09, UPMC Shadyside, West Wing Auditorium

 

MC03

$80

$50

Spirituality and Recovery, Part 2: How to Conduct Spirituality and Recovery Groups, 12/03/09, St. Joseph’s Spirituality Center

 

 

 

 

 

Total:

 

 

 

Payment

Total Enclosed:                           Method of Payment:

Check [  ]

VISA [  ]

MasterCard [  ]

AMEX [  ]

Discover [  ]

UPMC Account [  ]

(Check Payable to OERP/WPIC)  Check#____________________              

 

To be completed by Credit Card Users ONLY:
Card Number:                                                                                                            

Expiration Date:

Signature:

Security Code: (on back of card)

 

To be completed for UPMC account transfers ONLY:

Business Unit:

Dept. ID #:

Administrator's Name:

Administrator's Signature:

[  ] FEE WAIVED – ADDICTION MEDICINE STAFF (MC12 AND MC13 TRAININGS ONLY)

 

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