Gestalt Associates Training, Los Angeles - Summer Residential Registration

Los Angeles Training Programs Registration - Step 1 of 2

Course Selection(s)

Please select the course(s) you would like to register for:


Course - Gestalt Therapy Training	Payment Selection
Sampler	$25
Gestalt Therapy Training	$600 (deposit)	$1800(full fee)
Supervision Course	$100


Course - Relationships and Marriage 101	Payment Selection
Couples	$250
Individual	$150
Couple (with 1 Student)	$200
Individual (Student) , GATLA Trainee $120 OR Five (5) Persons Registerning Together ($120 each)	$120

Certification - Gestalt Therapy

Would you like to be certified by GATLA? (see explanation)	Fee
Yes No	$300.00

Participant Information - required fields are in bold

Name
Address Line 1
Address Line 2
City
State/Province
Zip/Postal Code
Country
Work Phone
Mobile Phone
Home Phone
Fax
Email
Highest Relevant Degree
Occupation
Please indicate if you would like CE Credit
If yes, please provide license name and number
How did you hear about this program?

Complete the following section only if you are applying for the Gestalt Therapy Training Program.
Current Position and Work Setting:

Previous Gestalt therapy training, including when, how long and with whom:
Non-Gestalt therapy training, including when, how long and with whom:

Personal psychotherapy, including when, how long, with whom and psychotherapeutic orientation (optional):

Persons attending either workshop for the first time, please provide 3 professional references including name, address, phone, fax and e-mail. These should be people who know your work as well as people who know you personally.:

Professional Reference #1:
Professional Reference #2:
Professional Reference #3:

Check here if paying by check. Make check payable to and mail to: GATLA 1460 Seventh Street, Suite 300 Santa Monica, CA 90401