ABN 15 211 513 464

The 2016UCRH Training Application Form

The 2016 UCRH training program features:

  • the UK-developed CBT online programs, OCTC Online and PRAXIS, which are offered at discounted prices for Australians, which continue to be popular
  • We may run some online self-experiential programs – watch this space

NB After 7 years of Byron workshops, we are taking a ‘gap year’ and not running any programs in Byron this year. We’ll return in 2017 with a fresh program.

Overleaf you will find the application form for the workshops and online programs. Please complete this and scan to , or fax or send by mail to UCRH fax or mailing address as below.

The 2016 UCRH Training Application Form

Title:______Surname: ______First Name: ______

Mailing Address:
City:State: Post Code:

Position: ______Employer:______

Phone: (____) ______Fax: (____) ______Mobile: ______

Email address in CAPITALS, very legibly please on next line: ______

[

If you are a therapist/counselor, please give details of your previous counselling or therapy experience

Years as a qualified mental health professional ______What profession? ______

Are you registered with a professional body?  Yes  No If so, which one? ______

If not a mental health professional, what background? ______

If you are a therapist/counsellor, what is your main therapeutic approach?______

How long have you been practicing? ______

Registration Fees (All prices are inclusive of GST) -

Online CBT Training

PRAXIS CBT Online (foundational CBT skills)Research Price$440

OCTC Online (advanced CBT skills) * Research Price$550

* Before registering for OCTC online, please follow cbttraining website instructions and go to the demonstration videos on OCTC online to ensure you have sufficient bandwidth to view the videos.

TAX INVOICE

SEND PAYMENT TO:

CBT Training, University Centre for Rural Health

PO Box 3074, Lismore NSW 2480

ABN 15211513464

I enclose a cheque for AUD$ ______made payable to:

University Centre forRural Health

Or

for credit card payments: post (as above) or FAX to

CBT training: Fax: +61 2 6678 0896


Please debit my credit card: MasterCard Visa

Name on card: ______

Card No: ______/______/ ______/______

Expiry Date _____ / _____ AMOUNT BEING PAID: $ ______(GST inclusive)

Cardholder’s Signature ______

Payment for: ______

(Please indicate above the course/s you will be attending.)

TERMS AND CONDITIONS OF REGISTRATION

CONFIRMATION OF REGISTRATION only occurs when payment is processed after eligibility has been confirmed. (We will confirm your registration by email).

CANCELLATIONS: Registration can be cancelled with a full refund less a $50 cancellation fee up to 4 weeks before the workshop commences. Thereafter no more than half of fees can be reimbursed

(until the day before the workshop) unless we are able to find a new participant to replace you. Unfortunately no refunds are payable if you are unable to attend on the day due to illness or other personal circumstances.

REGISTRATION TRANSFER: Registration IN FULL may be transferred to another person subject to eligibility being applied for and approved no less than a week before the workshop and with a $50 administration fee. However, unused parts of training registration CANNOT be transferred to another person and multi-day registrations cannot be shared.

I am aware that the fees do not include lunch or accommodation.

Incomplete application forms cannot be processed and may need to be returned. Please check your form before sending.

I HAVE READ the TERMS AND CONDITIONS OF REGISTRATION and understand and accept these. (please tick)

Signature ______Date ______

PO Box 3074, Lismore NSW 2480 - Phone: +61 2 6620 7570 - Fax: +61 2 6678 0896

Web: Email: