Ticket Type
*
Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Type of Consultation
*
Foundational Training (Institute for Creative Mindfulness)
Certification
Consultant-in-Training
Other
If other selected (or N/A):
Who did you complete your foundational training with?
Institute for Creative Mindfulness
Other
If other selected (or N/A)?
When did you complete your foundational training?
Attendance
*
Teleconference
I verify that I understand the group guidelines listed on the consultation website
*
Yes
No
I verify that I understand the cancellation policy
*
Yes
No
My Products
*
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Private Practice/Standard Rate: 2 hour group
$
125.00
# of groups registering for
1
2
3
4
5
6
7
8
9
10
Non-profit employee: 2 hour group
$
85.00
# of groups registering for
1
2
3
4
5
6
7
8
9
10
ICM Foundational Trainee: 2 hour group
$
85.00
# of groups registering for
0
1
2
3
4
5
6
7
8
9
10
11
Lunchtime 1 hour Group
$
50.00
# of groups registering for
1
2
3
4
5
6
7
8
9
10
EMDR Therapy Consultation Retreat
$
200.00
EMDR Consultation Bundle: 5 prepaid groups
$
531.25
EMDR Consultation Bundle (Trainee/Agency): 5 prepaid groups
$
361.25
WAITLIST
$
Free
Total
$
0.00
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