Show your support for the Self Psychology Page
by printing this Registration Form and using it
Direct all inquiries to:
PROFESSIONAL CONFERENCE
MANAGEMENT, INC.
7916 Convoy Court
San Diego, California 92111-1212
USA
Email: pcminc@pcmisandiego.com
Phone: 619-565-9921
Fax: 619-565-9954
22nd Annual International
Conference on The Psychology of The Self
SELF PSYCHOLOGY REFLECTS ON ITS CORE CONCEPTS
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. 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 THURSDAY AFTERNOON WORKSHOPS (Fees are listed in US $) | Postmarked By Sept. 23 | Postmarked After Sept. 23 |
| $ 45 | $ 60 | |
| Optional Thursday Afternoon Workshops (Select one): | A. The Spontaneous Self of the Analyst: Exercises in Improvisation | |
| B. MEET THE AUTHOR: Self Experiences in Group: Intersubjective and Self Psychological Pathways to Human Understanding | ||
| C. Optimal Responsiveness: The Application of Specificity Theory in Relational Self Psychology (Part I) | ||
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| PRE-CONFERENCE PROGRAM REGISTRATION FEES (Fees are listed in US $) | Postmarked by Sept. 23 | Postmarked after Sept. 23 |
| 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. Child Therapy Course |
| 2. Advanced Course** | 4. Literary Rendition of a Severe Self-Disorder |
** PRE-CONFERENCE ADVANCED COURSE
If you are registering for the Pre-Conference Advanced Course, 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._____Howard Baker, MD/Margaret M. Baker, PhD _____Jule Miller, Jr., MD
_____Shelley R. Doctors, PhD _____Andrew P. Morrison, MD
_____James L. Fosshage, PhD _____Donna M. Orange, PhD, PsyD
_____Paula B. Fuqua, MD/Sheldon J. Meyers, MD _____Estelle Shane, PhD
_____Ruth Gruenthal, MSW/Hazel R. Ipp, PhD _____Morton Shane, MD
_____Frank M. Lachmann, PhD _____David M. Terman, MD
_____John A. Lindon, MD _____Marion D. Tolpin, MD
_____Arthur Malin, MD/Naomi R. Malin, DSW, PsyD _____Ernest S. Wolf, MD/Allen M. Siegel, MD
*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 (Fees are listed in US $) | Postmarked By Sept. 23 | Postmarked After Sept. 23 |
| Professional | $325 | $355 |
| Student* | $195 | $215 |
*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
Please refer to the program and indicate your preferences in the spaces provided.
SESSION A: Saturday Morning 10:30 am - 12:00 pm
1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____
SESSION B: Saturday Afternoon 2:15 am - 3:45 pm
1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____
SESSION C: Saturday Afternoon 4:15 pm - 5:45 pm
1st Choice No._____ 2nd Choice No._____ 3rd Choice No._____
SESSION D: Sunday Morning 8:30 -10:00 am
1st Choice No._____ 2nd Choice No._____ 3rd 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 US$35 in advance, US$40 at the conference (based on space availability).
OPTIONAL SATURDAY EVENING CONFERENCE RECEPTION
A light Dinner Buffet followed by dancing to Sandy Vine and the Midnights. The fee for conference registrants and guests are US$35/each in advance, US$40/each at the conference.
REGISTRANT AND GUEST MEAL TICKETS
Conference registrant and guest tickets may be purchased for the Saturday Luncheon and the Saturday Evening Reception; guest tickets may be purchased for the Continental Breakfasts and Reception combined.
| In Advance | At the Conference | |
| Registrant Luncheon Ticket | $35 | $40 |
| Registrant Reception Ticket | $35 | $40 |
| Guest Conference Reception Ticket | $35 | $40 |
| Guest Breakfasts & Conference Reception Tickets | $60 | $65 |
| Guest Luncheon Ticket | $35 | $40 |
| TRANSLATED PANEL PAPERS | $25/set | |
| (select preferred language) | French | 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 | $_________ |
| Select One: | ||
| 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
* A US$20.00 fee will be assessed for returned checks.
NOTE: Please make hotel reservations directly with The Toronto Hilton Hotel.