International Society for the Study of Trauma and Dissociation

Dissociative Disorders Psychotherapy Training Program (DDPTP)

The information for all fields in this form must be completed or it will be returned.
Registration for seminar located in:
                                    Registration   no.  ________

Please read all of these instructions before downloading this page: This form is for persons who have contacted their local seminar faculty and have already been accepted in the DDPTP. ISSTD has been notified of your acceptance and you have been given a registration number. Your registration is complete when you fax this form with a copy of your current valid license for clinical practice in your local jurisdiction (or, if in training, a letter of recommendation from the chairperson of your training program/department) to the fax number at the bottom of this page, and payment is approved by your credit card company. You wil be notified of a completed registration via email (preferred), or fax, as soon as possible. Please help us keep our administrative costs down by including your email address. We do not sell addresses. This is for use in this course only.
Fees: Registration for ISSTD Members:$385, for Non-ISSTD Members: $435. If you wish to have CEU credit please add $40 (available only in U.S. and Canada, but not for online course). This fee includes copyright fees and the course materials. ALL FEES ARE IN U.S. DOLLARS. If you withdraw from the course less than 15 days priro to its local starting date, there is a $25 non-refundable charge. Registration is limited to 12 participants per face-to-face location. Once the course starts no new students can be accepted. The course fee is not refundable if you withdraw from the course after two weeks prior to its start, unless an acceptable replacement for your registration is found, in a timely fashion, prior to the start of the course. Refund of fees, and acceptance at that time, is the decision of the course Directors. All materials used for this course are subject to copyright laws and are not for duplication or distribution by course participants. Sharing materials from this course is a violation of copyright law and ISSTD rules.
Please download this form by simply pressing the <Print> button on your browser. Please fill in all fields of this form. Information provided is only for this course and will not be sold, or otherwise distributed or used in any other fashion.

Name:(last):                                                  (first):                                            (initial):
Address: (street)
City                                                             State                                Zip _______+_____
Credentials     LCSW     PhD     MD   Other_______ License#____________ Jurisdiction:
Office Telephone: Home Telephone:
Fax Number: Email address:
ISSTD Member___ Non-Member___ CEUs (add $40) ___ I am attending the:
Standard Course___   Advanced Course___
Credit Card (circle one) Visa   MC   AMEX   Discover
Card No:		 Total fee (USD) $________
Expiration date  ____/____

Signature (read below before signing)  

Faxing this form to ISSTD, with your signature, signifies acceptance of the terms and conditions for this course offering, noted above, and that you are a licensed clinician with a current valid license to practice your specialty in the jurisdiction indicated.

Please fax this form to Trauma Recovery Consultants, 248/546-8070,
or mail this form to:Trauma Recovery Consultants, 415 S. West St, Suite 150, Royal Oak, MI 48067
My check (in USD from US bank) is enclosed for: $__________ Make checks payable to “Trauma Recovery Consultants."