Contact and Demographic Information
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Ambassador Program	Check here if you were invited to attend the conference as a member of our Ambassador Program.
How did you learn about the conference?	Previously attended NSGP Website NSGP Twitter NSGP Newsletter NSGP Email Announcement NSGP (large) Conference Postcard NSGP Facebook Page NSGP Full Conference Brochure NSGP Blog Colleague/Friend AGPA Newsletter AGPA Website CGTA Print Ad MA Psych Assoc Web Ad MAPP Print Ad NASW Focus Print Ad NEPsy Print Ad Professional Listserve Invited as Ambassador Other (Please indicate other source in the box to the right)
Membership Status	Member New Member Non-Member
Student Status	Fulltime Student NSGP Training Program Student
Is this your first NSGP Conference?	Yes, this is my first conference No, this is not my first conference
Professional Discipline	Alcoholism/Substance Abuse Counselor Clinical Nurse Specialist Mental Health Counselor Pastoral Counselor Physician Psychologist Social Worker Other
No. of Years of Group Therapy Experience	0 - 2 3 - 7 8 - 14 15 or more
Participation Agreement	Effective group therapy training is best facilitated by both participation in a group led by experts and study of the resulting group process. While NSGP provides training groups rather than therapy groups, the experience can lead to difficult or uncomfortable feelings in the participants. Because they involve group participation, you should not register for Institutes or volunteer for the Demonstration Group if you prefer to avoid this risk. By registering or volunteering you acknowledge that you have been informed of this risk and consent to participate. Yes, I have read the statement above and consent to participate in groups.
Program Selections				Select Rates Below
3-Day Saver Package (Save $ compared to 'a la carte' selections)	Includes ALL programs (please make selections below)	Includes All Programs except for Special Presentations (please make selections below)		All Programs (Member): $450 All Programs (Non-Mem): $535 All Programs (Student): $220 All but Spec Pres (Member): $340 All but Spec Pres (Non-Mem): $430 All but Spec Pres (Student): $185
Special Presentation	Your Mind in Mine: Empirical Foundations and Clinical Applications of Mentalization Therapies	Saturday PM: Part I -- Theory and Empiricle bases of the concept of Mentalization	Sunday PM: Part II -- Essential components of Mentalization-based treatment in Ind. & Group Tx	1 Day (All Registrants): $45 Both Days (All Registrants): $80
Day-Long Experience Group	1st Choice I-1: Weiss I-2: Shapiro I-3: Shay I-4: Carmichael & Tomb I-5: Haut I-6: Krugman & Lundy I-7: Altfeld I-8: Bernstein I-9: Keezell I-10: Kramer Slepian I-11: Ward I-12: Giraldo	2nd Choice I-1: Weiss I-2: Shapiro I-3: Shay I-4: Carmichael & Tomb I-5: Haut I-6: Krugman & Lundy I-7: Altfeld I-8: Bernstein I-9: Keezell I-10: Kramer Slepian I-11: Ward I-12: Giraldo	3rd Choice I-1: Weiss I-2: Shapiro I-3: Shay I-4: Carmichael & Tomb I-5: Haut I-6: Krugman & Lundy I-7: Altfeld I-8: Bernstein I-9: Keezell I-10: Kramer Slepian I-11: Ward I-12: Giraldo	Member: $135 Non-Member: $170 Student: $75 Standby Option: $65
	If my choices above are either full or closed, please (select one):
	Assign me to a general psychodynamic group		Refund my Institute fee
	REDUCED FEE STANDBY OPTION: You may attend a Day-Long Experience Group for a reduced fee of $60 in return for agreeing to give the committee the flexibility to assign you to any Expereince group, as needed. You may indicate your first, second and third choices above. When possible, we will honor your preferences. However, the committee may assign you to another Experience Group, as necessary, to balance group membership. You will be informed of your assignment when you pick up your tickets. If we cannot accommodate you for this standby option, you will have the option to pay the regular fee and choose among the available Experience Groups.  This offer is available on a first-come, first-served basis for up to 10 people. Standby Option (make three choices above, which we may honor)
Workshops	Please list, in order of preference, your workshop choices by number. 2nd and 3rd choices are HIGHLY recommended, in case your 1st choice is full. If no backup choices are indicated, the committee may choose to place you in an alternate/undersubscribed workshop.
Saturday Morning	1st Choice W-1: Rice, Albert, et al. W-2: Anderson-Perales W-3: Goldfinger W-4: Hoekstra W-5: Juraleva & Suzuki W-6: Mendelsohn, et al. W-7: Shay W-8: Weber	2nd Choice W-1: Rice, Albert, et al. W-2: Anderson-Perales W-3: Goldfinger W-4: Hoekstra W-5: Juraleva & Suzuki W-6: Mendelsohn, et al. W-7: Shay W-8: Weber	3rd Choice W-1: Rice, Albert, et al. W-2: Anderson-Perales W-3: Goldfinger W-4: Hoekstra W-5: Juraleva & Suzuki W-6: Mendelsohn, et al. W-7: Shay W-8: Weber	1 Wrkshp (Member): $70 1 Wrkshp (Non-Member): $85 1 Wrkshp (Student): $45 2 Wrkshps (Member): $130 2 Wrkshps (Non-Mem): $155 2 Wrkshps (Student): $65 3 Wrkshps (Member): $180 3 Wrkshps (Non-Mem): $220 3 Wrkshps (Student): $90 3 Wrkshps+Demo (Member): $230 3 Wrkshps+Demo (Non-Mem): $285 3 Wrkshps+Demo (Student): $120
Saturday Afternoon	1st Choice W-9: Albert W-10: Phillips W-11: Sharp W-12: Krugman W-13: Barnes&Schwrtzbrg W-14: Fuller W-15: Gans & Silk W-16: Kinley	2nd Choice W-9: Albert W-10: Phillips W-11: Sharp W-12: Krugman W-13: Barnes&Schwrtzbrg W-14: Fuller W-15: Gans & Silk W-16: Kinley	3rd Choice W-9: Albert W-10: Phillips W-11: Sharp W-12: Krugman W-13: Barnes&Schwrtzbrg W-14: Fuller W-15: Gans & Silk W-16: Kinley	Note: the Full-Day Workshop counts as two workshops (when choosing the fee).
Sunday Morning	1st Choice W-17: S. Cohen W-18: Counselman & Rutan W-19: Flores W-20: Kuerer Gangi W-21: Grunblatt W-22: Levy W-23: Silverstein W-24: F. Weiss	2nd Choice W-17: S. Cohen W-18: Counselman & Rutan W-19: Flores W-20: Kuerer Gangi W-21: Grunblatt W-22: Levy W-23: Silverstein W-24: F. Weiss	3rd Choice W-17: S. Cohen W-18: Counselman & Rutan W-19: Flores W-20: Kuerer Gangi W-21: Grunblatt W-22: Levy W-23: Silverstein W-24: F. Weiss
Demonstration Group	Attachment Theory and Group Psychotherapy			Member: $85 Non-Member: $100 Student: $50
ADD UP fees in the right hand column and enter SUBTOTAL of PROGRAM FEES   >				* required
Early Bird Discount		Early Birds subtract $30 if registering by May 1st!
1st Time Attendee Discount		First-time Attendees take 25% off Program Fees
SUBTRACT any discounts and enter TOTAL PROGRAM FEES  >				* required
On-Site Lodging (Sign-up by 5/17/11)	Thursday Night	Friday Night	Saturday Night	ROOM RATES 1 Night Single Occupancy: $63 1 Ngt Sngl Occ., Priv. Bath: $70 2 Nights Single Occupancy: $126 2 Ngts Sngl Occ., Priv. Bath: $140 3 Nights Single Occupancy: $189 3 Ngts Sngl Occ., Priv. Bath: $210 1 Night Double Occupancy: $50 1 Ngt Dbl Occ., Priv. Bath: $58 2 Nights Double Occupancy: $100 2 Ngts Dbl Occ., Priv. Bath: $116 3 Nights Double Occupancy: $150 3 Ngts Dbl Occ., Priv. Bath: $174
	I need overnight parking with my lodging request (to be paid separately to garage).
Automobile Information (for Overnight Parking)
ADD any lodging costs to ENTER GRAND TOTAL   >				* required
Mailing Tickets: People registering by May 1st will receive their tickets in the mail. Tickets will be mailed by June 1st. People registering after May 1st will pick up their tickets at the conference. Cancellation Policy: No refunds for cancellations after May 1st. Cancellations require written notification.		NSGP Member Rates are available only to those whose membership is in effect or those who have applied for membership by May 1st, 2011. Student Discount applies to full time students only. Need Help? Because of the many conference choices, registering can be confusing. For questions about the registration process, call or email Joe DeAngelis at 781-646-4468 or joe.deangelis.licsw@gmail.com.		BEFORE hitting the Submit button below, please WRITE DOWN your GRAND TOTAL. You will need to enter this on the payment page.