Brainspotting Level I Registration

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
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Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
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Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
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Central African Republic
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Chile
China
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Cook Islands
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Cote d'Ivoire
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Dominican Republic
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Egypt
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Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
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Indonesia
Iran
Iraq
Ireland
Israel
Italy
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Japan
Jersey
Jordan
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Kenya
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North Korea
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Kyrgyzstan
Laos
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Lebanon
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Liberia
Libya
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Lithuania
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Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
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Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
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Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
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Samoa
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Senegal
Serbia
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
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Tokelau
Tonga
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Trinidad and Tobago
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Turkey
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Tuvalu
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Isle of Man
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Western Sahara
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Other
Country
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Phone Number* This field is required.
Area Code
Phone Number
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Profession* This field is required.
Licensed Clinical Social Worker
Psychologist
MD
Marriage And Family Counselor
Art Therapist
Coach
Student
Intern/Pending License
Other Helping Professional
LPC
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If other Helping Profession; which one* This field is required.
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If StudentSchool/Program/Anticipated Graduation Date
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State Licensed by and License Number
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Start date for Training and Location* This field is required.
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Group Code, If applicable
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Name and Professional Designation as you would like it to appear on your certificate* This field is required.
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Do you want David's book in paperback or Kindle* This field is required.
Paperback
Kindle
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We are excited to be teaching you this Phase 1 Brainspotting Class and are dedicated to creating a safe place for all to learn. Please fill out this section of the form to tell us a little abt you before class begins. You can skip questions you do not feel comfortable with.
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Name you would like to be called in class* This field is required.
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your pronouns
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Is there any part of the training you know you will not be able to attend? Please explain below. This training requires attendance at all practicums, but it's helpful for us to know if you might have to step away for an hour or leave early one day so that we can manage the practicums and help you make up anything that you might miss.
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Would you be interested in being one of the four demos we have scheduled? If so, please give us a brief description of what you would like to work on in the next place on this form. If we have too many volunteers please know that you will have 4 opportunities to work in your practicums.* This field is required.
YESNO
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If you indicated that you wanted to be a demo subject
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Practicum PartnersIt is important to us that everyone feels comfortable in our training. That said, is it important to you that you are paired with someone of a certain population? For example, another LGBTQ person, a BIPOC, or even someone of the same gender? Or is there something else we need to know to successfully partner you up in the practicums? Please let us know. We will make every effort to honor your request, although we are not always able to do so.
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Equity, Diversity, and Inclusivity Statement: We are committed to creating an equitable, diverse, and inclusive community where everyone is welcome. In doing so, we promise to make every effort to recognize, address and eradicate any and all forms of racism, oppression, intolerance, negative judgments, and mistreatment directed toward marginalized communities and individuals. We also understand that bias may not always be intended. We ask that everyone commit to doing their best with an open and humble willingness to grow and learn. We also ask that you join us in committing to act in a respectful manner and to maintain confidentiality related to the work of each participant. Deb and Sue and our entire organization strive to exemplify these values for all staff, clients, and training participants. Thank you for helping us to uphold these commitments during your time with us.
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PLEASE NOTE THAT REGISTRATION FOR THIS CLASS IS NOT COMPLETE UNTIL YOU HIT SUBMIT BELOW AND FORWARD PAYMENT FOR THE CLASS.

We offer NJ NASW CEs for free. Some states may accept these CEs. Please check with your licensing board.

The cost of the class changes based on when you register. Please go to www.coherentself.com and look for the Brainspotting Class you are signing up for to see the current cost for the class.

To pay, please use Zelle and send the money to SPinco96@yahoo.com or to phone number 201-747-6789, or Venmo @Susan-Pinco. If you prefer to pay by check, please email spinco96@yahoo.com to notify her of your intention to send a check and she will notify you of the address to mail the check to. You may also pay via PayPal @DrSusanPinco. If your paypal account is associated with a credit card you will be responsible for the 4% processing fee. You may also ask for a square invoice that carries a processing fee of 3% which will be included in your total.
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