Make checks payable to Self Psychology Fund. Full payment must accompany registration form. All fees must be paid in U.S. FUNDS DRAWN AGAINST A U.S. BANK. VISA and MasterCard also will be accepted. Fees listed are in U.S. dollars. Please use one form per registration. Form may be photocopied.

(Please print or type)

Last Name ____________________________________________________
Degree(s) ____________________________
                 (to be printed on your name tag)

First Name ________________________________________________
Middle Initial ______________________

Address _________________________________________________________________________

City ______________________________
State _____Postal Code ______________
Country _________________

Phone Number (_____) _______________________
Fax Number (_____)_________________________________

E-Mail Address_______________________________________________________________

Profession____________________________
State/Professional License No._______________________________

(for Continuing Education Certificate)

Mailing Label Code__________________________ (To help us minimize multiple mailings, please list the number or code found on the brochure mailing label even if it was not addressed to you.)

OPTIONAL PRE-CONFERENCE WORKSHOP FEES

Optional Pre-Conference: 

Workshops (Select one)  

A. The Spontaneous Self of the Analyst: Exercises in Improvisation

B. Gender and Sexuality: Where Are We Now?

C. Optimal Responsiveness: The Application of Specificity Theory in Relational Self Psychology (Part I)

D. Self Psychology and Child Treatment

OPTIONAL PRE-CONFERENCE COURSE REGISTRATION FEES

Pre-Conference Courses (Select one): 

1. Introductory Course  

2. Clinical Case Consultation

3. Marital Therapy Course

4. Group Therapy Course

PRE-CONFERENCE CLINICAL CASE CONSULTATION TRACK

If you are registering for the Pre-Conference Clinical Case Consultation Track, please indicate your choices for the Master Classes (small supervisory groups) in order of preference from 1-8. YOU MUST ATTEND THE GROUP TO WHICH YOU ARE ASSIGNED. Assignments will be made strictly on a first-come, first-served basis.

_____Joseph D. Lichtenberg, MD _____Ernest S. Wolf, MD

_____Frank M. Lachmann, PhD _____Alan R. Kindler, MBBS/Shelley R. Doctors, PhD

_____Anna Ornstein, MD _____James M. Fisch, MD

_____Paula B. Fuqua, MD/Sheldon J. Meyers, MD _____Jeffrey L. Trop, MD

_____Marian D. Tolpin, MD _____Arthur Malin, MD/Naomi Malin, DSW, PsyD

_____Iris Hilke, MA (Child Analysis) _____Rosalind C. Kindler, MFA/Jacqueline J. Gotthold, PsyD (Child Therapy)

*Student registrations MUST be accompanied by a letter from the training director verifying full-time status; photocopies of student ID will not be accepted.

MAIN CONFERENCE REGISTRATION FEES

 *Student registration MUST be accompanied by a letter from the Training Director verifying full-time status, photocopies of student ID will not be accepted.

Because meeting room capacities are limited by local fire laws, maximum capacities will be strictly adhered to for the concurrent sessions. We regret that we are unable to make exceptions. To avoid disappointment, we urge you to register early to be assured of attending your preferred sessions.

ORIGINAL PAPERS AND WORKSHOPS

SESSION A: Saturday Afternoon 2:15 - 3:45 PM

1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____ 4th Choice No._____

SESSION B: Saturday Afternoon 4:15 - 5:45 PM

1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____ 4th Choice No._____

SESSION C: Sunday Morning 8:30 -10:00 AM

1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____ 4th Choice No._____

OPTIONAL SATURDAY LUNCHEON FOR CONFERENCE PARTICIPANTS

An optional luncheon will be held on Saturday beginning at 12:15 PM. The fee for the lunch will be $35 U.S. in advance, $40 U.S. at the conference (based on space availability).

OPTIONAL SATURDAY EVENING CONFERENCE RECEPTION

A light Dinner Buffet followed by dancing to The Good Times Orchestra of Chicago. The fee for conference registrants and guests is $35 U.S./each in advance, $40 U.S./each at the conference.

GUEST MEAL TICKETS

Guest tickets may be purchased for the Saturday Luncheon, the Saturday Evening Reception and for the Continental Breakfasts and Reception combined.

Guest's Name____________________________________________________

TRANSLATED PANEL PAPERS $25/set (Italian)

Will you need any special assistance at the conference? Please list your needs:

_________________________________________________________________________________

_________________________________________________________________________________

Totals:

TOTAL AMOUNT DUE $_________

A check is enclosed payable to Self Psychology Fund.

Bill my: VISA MASTERCARD

Account #___________________________________________________
Exp. Date__________________

Signature_____________________________________________________________________________
                      (as it appears on the card)

Mail to:

Self Psychology Conference
7916 Convoy Court
San Diego, CA 92111-1212
USA

A $20.00 U.S. fee will be assessed for returned checks.

NOTE: Please make hotel reservations directly with The Chicago Marriott Downtown Hotel.

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