LPTI Training Cohort Registration

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Welcome to the LPTI 2021-2022 Monthly Training Cohort October thru June

Please review the attached cohort overview before completing this registration form.

Which cohort day will you participate in? (dates included in LPTI cohort overview attachment) *

The second Wednesday of the Month

The second Saturday of the month (except Jan and Mar are the third Sat.)

Please check the box if you are able to be flexible with the day you participate (in case groups are extremely unbalanced)

I am able to do either day.

Contact Information

Please fill out the following basic information.

What is your Name? *

What's the best phone number to reach you? *

What's the best email to reach you? *

What is your home address?

Who is your emergency contact? (Name, relation) *

What is the best phone number for your emergency contact? *

Educational and Professional Background

The following questions are about your background

Education (Highest Degree, Year Conferred, Name of Institution, Major/Area(s) of Concentration): *

Current Interests/Studies: *

Licensures or Certifications, if applicable:

If not a current student/participant with LPTI, please list any previous training or experience with psychodrama:

Training in other experiential approaches, if applicable:

LEARNING GOALS AND EXPECTATIONS

In what settings are you currently or do you plan to apply the concepts and skills you acquire in this workshop? With whom? *

What are you hoping to learn/do/experience/observe from the workshop? (Be as broad or specific as you like.) *

What strengths/resources do you bring to the workshop? *

Anything else you would like to say about your interests, preferences, and/or needs for this training experience?

How will you pay for the first session? ($195) *

I will mail a check made out to LPTI to Cathy Nugent @ 6636 Park Hall Drive, Laurel, MD, 20707, United States

I will pay by card on the first day ($5 surcharge)

How will you pay for the first session? ($195) *

I will mail a check made out to LPTI to Cathy Nugent @ 6636 Park Hall Drive, Laurel, MD, 20707, United States

I will pay by card on the first day ($5 surcharge)

Please see the link below if you will need financial assistance (scholarship or work study trade) to complement your preferred payment option.

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