CONFERENCE
REGISTRATION FORM
ENHANCING THE THERAPEUTIC EXPERIENCE
CLICK
HERE FOR 2002 REGISTRATION
WASHINGTON, DC
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
Postmarked Postmarked
By Oct. 12 After Oct. 12
"
$ 45 "
$ 60
Optional Pre-Conference Workshops: (Select One)
" A. Studies in Intersubjectivity: Affects, "
D. Infant and Mother Treatment Models
Selfobjects and the "Intersubjective Sensibility" "
E. The Self and Orientation: The Next Steps
" B. Art, Creativity and Self Psychology ".
F. The Impact of Learning Disabilities on Children’s
" C. The Work of Stephen A. Mitchell and
Self Psychology and Adolescents’ Sense of Self
OPTIONAL PRE-CONFERENCE COURSE REGISTRATION FEES
Postmarked Postmarked
By Oct. 12 After Oct. 12
If taken with Main Conference "
$135 "
$160
Student*, if taken with Main Conference "
$ 70 "
$ 80
Pre-Conference Only "
$160 "
$185
Pre-Conference Only - Student "
$ 90 "
$100
Pre-Conference Courses (Select one): "
1. Introductory Course "
3. Couples Therapy Course
"
2. Advanced Course d
"
4. Group Therapy Course
d PRE-CONFERENCE ADVANCED COURSE IN SELF
PSYCHOLOGY
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 1-10. YOU MUST ATTEND THE
GROUP TO WHICH YOU ARE ASSIGNED. Assignments will be made strictly on a
first-come, first-served basis.
_____Alan R. Kindler, MD/Shelley R. Doctors, PhD _____Marian Tolpin,
MD, MD
_____Joseph D. Lichtenberg, MD _____Anna Ornstein, MD
_____Ruth Gruenthal, MSW/Hazel Ipp, PhD _____Ernest Wolf, MD
_____George Atwood, PHD _____Philip Ringstrom, PhD, PsyD/Naomi Malin,
DSW
_____Sanford Shapiro, MD _____Howard Bacal, MD/Estelle Shane, PhD
*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
Postmarked By Oct. 12 Postmarked After Oct. 12
Professional $330 $360
Student* $200 $220
*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 $40 U.S. in advance, $45 U.S. at the
conference (based on space availability).
OPTIONAL SATURDAY EVENING CONFERENCE RECEPTION
A light Dinner Buffet followed by dancing to The Ben Stolorow Trio. The
fee for conference registrants and guests is $40 U.S./each in advance, $45
U.S./each at the conference.
GUEST MEAL TICKETS AND TRANSLATED PAPER (ITALIAN ONLY)
Guest tickets may be purchased for the Saturday Luncheon, the Saturday
Evening Reception and for the Continental Breakfasts and Reception
combined.
In Advance At the Conference
Registrant Luncheon Ticket "
$40 "
$45
Registrant Reception Ticket "
$40 "
$45
Guest Reception Ticket "
$40 "
$45
Guest Breakfasts & Reception Tickets "
$65 "
$70
Guest Luncheon Ticket "
$40 "
$45
TRANSLATED PANEL PAPERS "
$25/set (Italian)
Guest's Name_______________________________________________________
Will you need any special assistance at the conference? Please list
your needs:
_________________________________________________________________
_________________________________________________________________
Totals:
Optional Pre-Conference Workshop Fee $_________
Optional Pre-Conference Course Fee $_________
Main Conference Fee $_________
Optional Luncheon for Registrants $_________
Optional Reception for Registrants $_________
Guest Tickets $_________
Translated Panel Papers $_________
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
Grand Hyatt Hotel. | 