PLEASE PRINT THIS FORM AND MAIL IT WITH YOUR CHECK
------------------------------------------------------------------------------------------------------------------------Registration Form

Insight and Intervention: A Clinician Looks at Parent Loss

A Series of Workshops Designed for Mental Health Professionals

I wish to enroll in the following workshops:

____ Jan. 20, Violence, Trauma, and Loss
____ Jan. 27, The Basic Elements of the Treatment Process with a Bereaved Child
____ Feb. 3, Similarities and Differences Between Loss by Death and Loss by Divorce
____ Feb.10, The Impact of a Depressed Parent on the Child
____ Feb. 17,  The Trauma of Parental Abandonment
____ Feb. 24, How to Talk to Children about Death
____ March 3, Play Therapy with Bereaved Children
____ March 10, Countertransference Issues in Dealing with Bereaved Families

Please Print:

Name:___________________________________________________________________

Address: _________________________________________________________________

City, State, Zip:_____________________________________________________________

Daytime Phone: (_____) _________________ Evening Phone: (_____) __________________

Profession : ________________________________________________________________

Amount enclosed ($30 per workshop or all eight workshops for $180): $__________________

Fees nonrefundable after 1/14/06.

Please return the completed registration form and check payable to the Institute for Psychoanalysis to:

Institute for Psychoanalysis
122 S. Michigan Ave, Suite 1300
Chicago, IL 60603

For additional information, phone (312) 922-7474 or e-mail: [email protected]