Seminar Registration

Please note, fields marked with a * are REQUIRED.

Salutation* Mr. Ms. Dr.
Name*
Degree
License # Lic Exp
Address*
City* State*
Zip*
Phone* Fax
Email*
Profession Psychologist LCSW MFT Physician Nurse Counselor
Other:

 

Please select your classes, dates and locations

Seminar Title Bel Air/West LA Glendale
Suicide Prevention: New Interventions That Work
  Jul. 21
  Sep. 22
Legal and Ethical Guidelines for Managing Difficult Patients and Terminating Treatment
  Jun. 16
  Aug. 18
Sex, Porn and Addiction: Challenges to Romance, Intimacy, Fidelity and Attachment in the Digital Age
  Jun. 29
  Aug. 4

 

Multi Course Discount

Deduct 10% from total if you sign-up for 2 or more courses at the same time.

Method Of Payment
Charge My VISA MASTERCARD DISCOVER AMERICAN EXPRESS
Card Number Expiration Date
Payment Amount Security Code
Cardholder's Name
Signature (required only if mailing or faxing form)

 

If paying by credit card:

(1) click on the "submit" button above to register on-line OR

(2) print this registration form and fax it to:(805) 371-7443

If Mailing in Registration Form:

Check enclosed for $ (make payable to: Professional Psych Seminars)

If you have any further questions, please call Toll Free (877) 777-0668 or (805) 371-9443

or e-mail us at info@psychsem.com

Mail to:
Professional Psych Seminars Inc.,
PO Box 3174
Thousand Oaks
CA 91359-0174