PSYCHOTHERAPY WITH CHILDREN AND ADOLESCENTS

July 16 - 27, 2007 in Santa Barbara, California

IMPORTANT: PLEASE PRINT CAREFULLY. Typing is best.

Name

Address

City State Zip
Country

Home Phone

Office Phone

Fax No.

E-Mail_________________________ VERY IMPORTANT!

Use reverse side if necessary

1. Education

2. Professional Experience

3. What kind of work do you do now?

4. Do you have any Gestalt therapy experience or training? Please explain.

5. Why do you want to be in this program?

Please return this form, along with your $750. deposit, to 3761 Greggory Way, No. 5, Santa Barbara, CA 93105.
Checks may be made out to Violet Oaklander, Ph.D. or The Violet Oaklander Institute. You can cut and paste the application and send via e-mail and mail your deposit separately, if you like. (oaklander@gestalt.org.)

Outside the U.S.: send deposit in U.S. funds through international money order or a cashier's check from an international bank. We can give you the information if you would like to transfer money directly. You are responsible for all bank charges both at your end and our end.

Lodging and other information will be sent to you with your acceptance letter.
See training flyer for information regarding payment of balance and cancellation information.

 Questions? call (805) 563-0031 and leave a time when you can be reached.

or e-mail: oaklander@gestalt.org