APPLICATION FOR 2006-07 CERTIFICATION PROGRAM
Name:__________________________________________________ Email:__________________________________
Address:________________________City/State/Zip: __________________ Phone : W( )_________H( )________
Country: ________________________
Discipline: Medicine (Psychiatrist) Social Work Psychology Counselor Nursing
Other please name: ____________________
Educational History(University and Degree):___________________________________________________________
Current Employment: (Give title and setting):
If you are licensed, give state, licensure area and number
Apply for One:
Clinical and Academic Certificate Program {Payment of $1200 for full tuition or 3 payments of $450.00,
due: 1) upon acceptance; 2) January 1, 2007; and 3) March 1, 2007 (A late fee of $5 per month will added)
Advanced Certification Program
Academic Certificate Only
Audit Program
Self-Study Program (There is no initial late fee or registration deadline for this program option)
Do you require psychology/counseling CE hours? No Yes
Are you willing to do work/study scholarship in Fort Wayne, Indiana?
Please attach extra pages to supply additional information that would be helpful in evaluating your application.
Please include a current Curriculum Vitae (required).
PLEASE SUBMIT A NON-REFUNDABLE $50.00 TUITION DEPOSIT AND PROCESSING FEE PAYABLE TO
THE FREEMAN INSTITUTE FOR COGNITIVE THERAPY ALONG WITH THIS APPLICATION. NO APPLICATION
WILL BE PROCESSED WITHOUT TUITION DEPOSIT FEE. NON U.S.A. TUITION AND S/H IS EXTRA. PLEASE EMAIL
OR WRITE FOR DETAILS.
Videotapes of previous workshops with this program material for self-study are available below:
(check for tapes desired)
Videotapes of previous workshops with this program material for self-study are available below: (check for tapes desired)
___Interpersonal and Cognitive Therapy with Myrna Weissman, Ph.D. and Arthur Freeman Ed.D. ($100. 6 CE Hrs)
___Short-Term Treatment for Long Term Clients with Arthur Freeman, Ph.D. ($100. 6 CE Hrs)
___Cognitive and Gestalt Therapy--Finding Common Ground with Edward Smith, PhD and Jeffrey Young, PhD. (6 CE Hrs)
___Bipolar Disorders in Children and Adolescents with Robert Montgomery, PhD. (3-6 CE Hrs)
___The Southeastern Conference with Aaron T. Beck, MD, et.al.: Treating Personality Disorders &
Relationship/Couples Problems. (This is a special double tape @ $140.) (10 CE Hrs)
___Treatment of Panic and Hypochondriasis with David Clark, D.Phil. Oxford University, Oxford, England (6 CE Hrs)
___Ethical Considerations in the Diffcult Clincial Environments with John Kiehlbauch, Ph.D. (6 CE Hrs)
___Cognitive Therapy for Impulse Control Disorders with John Watkins, Ph.D., ABPP (6 CE Hrs)
___Generalized Anxiety Disorder & Panic Disorder with David Barlow, Ph.D. ($100., 6 CE Hrs)
Many other workshops on tape are available. Please ask for a complete listing of self study videotapes.
Videotapes are recorded with normal and hi-fi sound tracks and are unedited. The purchase cost for
each one-day tape is $85 (unless otherwise noted).
Please make checks payable to: The Freeman Institute for Cognitive Therapy
YOU CAN FAX REGISTRATIONS TO: (260) 969-5584
MAIL TO: Freeman Institute for Cognitive Therapy Number of Tapes x fee+ $5.s/h = Total*
10319 Dawson’s Creek Blvd, Suite J VISA MC Discover Number: _________________________
Fort Wayne, Indiana 46825 code on back of card (last 3 digits)_______ExpDate:
Name on Credit Card:_________________
Billing Zip Code:___________Country______________
* Independent audit or video taping is not permitted. Your canceled check will serve as receipt for registration.
* add $5/item for shipping and handling ($25./tape outside US)
The United States IRS allows a deduction for the cost of educational and training programs aimed at maintaining and improving professional skills. This
includes registration fees, meals, travel and lodging. Consult your tax advisor.
Name:__________________________________________________ Email:__________________________________
Address:________________________City/State/Zip: __________________ Phone : W( )_________H( )________
Country: ________________________
Discipline: Medicine (Psychiatrist) Social Work Psychology Counselor Nursing
Other please name: ____________________
Educational History(University and Degree):___________________________________________________________
Current Employment: (Give title and setting):
If you are licensed, give state, licensure area and number
Apply for One:
Clinical and Academic Certificate Program {Payment of $1200 for full tuition or 3 payments of $450.00,
due: 1) upon acceptance; 2) January 1, 2007; and 3) March 1, 2007 (A late fee of $5 per month will added)
Advanced Certification Program
Academic Certificate Only
Audit Program
Self-Study Program (There is no initial late fee or registration deadline for this program option)
Do you require psychology/counseling CE hours? No Yes
Are you willing to do work/study scholarship in Fort Wayne, Indiana?
Please attach extra pages to supply additional information that would be helpful in evaluating your application.
Please include a current Curriculum Vitae (required).
PLEASE SUBMIT A NON-REFUNDABLE $50.00 TUITION DEPOSIT AND PROCESSING FEE PAYABLE TO
THE FREEMAN INSTITUTE FOR COGNITIVE THERAPY ALONG WITH THIS APPLICATION. NO APPLICATION
WILL BE PROCESSED WITHOUT TUITION DEPOSIT FEE. NON U.S.A. TUITION AND S/H IS EXTRA. PLEASE EMAIL
OR WRITE FOR DETAILS.
Videotapes of previous workshops with this program material for self-study are available below:
(check for tapes desired)
Videotapes of previous workshops with this program material for self-study are available below: (check for tapes desired)
___Interpersonal and Cognitive Therapy with Myrna Weissman, Ph.D. and Arthur Freeman Ed.D. ($100. 6 CE Hrs)
___Short-Term Treatment for Long Term Clients with Arthur Freeman, Ph.D. ($100. 6 CE Hrs)
___Cognitive and Gestalt Therapy--Finding Common Ground with Edward Smith, PhD and Jeffrey Young, PhD. (6 CE Hrs)
___Bipolar Disorders in Children and Adolescents with Robert Montgomery, PhD. (3-6 CE Hrs)
___The Southeastern Conference with Aaron T. Beck, MD, et.al.: Treating Personality Disorders &
Relationship/Couples Problems. (This is a special double tape @ $140.) (10 CE Hrs)
___Treatment of Panic and Hypochondriasis with David Clark, D.Phil. Oxford University, Oxford, England (6 CE Hrs)
___Ethical Considerations in the Diffcult Clincial Environments with John Kiehlbauch, Ph.D. (6 CE Hrs)
___Cognitive Therapy for Impulse Control Disorders with John Watkins, Ph.D., ABPP (6 CE Hrs)
___Generalized Anxiety Disorder & Panic Disorder with David Barlow, Ph.D. ($100., 6 CE Hrs)
Many other workshops on tape are available. Please ask for a complete listing of self study videotapes.
Videotapes are recorded with normal and hi-fi sound tracks and are unedited. The purchase cost for
each one-day tape is $85 (unless otherwise noted).
Please make checks payable to: The Freeman Institute for Cognitive Therapy
YOU CAN FAX REGISTRATIONS TO: (260) 969-5584
MAIL TO: Freeman Institute for Cognitive Therapy Number of Tapes x fee+ $5.s/h = Total*
10319 Dawson’s Creek Blvd, Suite J VISA MC Discover Number: _________________________
Fort Wayne, Indiana 46825 code on back of card (last 3 digits)_______ExpDate:
Name on Credit Card:_________________
Billing Zip Code:___________Country______________
* Independent audit or video taping is not permitted. Your canceled check will serve as receipt for registration.
* add $5/item for shipping and handling ($25./tape outside US)
The United States IRS allows a deduction for the cost of educational and training programs aimed at maintaining and improving professional skills. This
includes registration fees, meals, travel and lodging. Consult your tax advisor.
