2017TEXAS LPC SUPERVISOR TRAINING COURSE REGISTRATION FORM

*Pre-Registration is required * Nonrefundable*

40Texas LPC CE Hours, Including 12Hours of LPC Ethics CE Hours

Two-day in-class course8:30AM to 6:30PM in San Antonio Texas PLUS complete 20-hour Wellspring Therapy Associates LPC Supervisor Self-Study Readings & Reflections PRIOR to class (provided by email and USPS mail after registration is complete).

OR SELECT SIX-HOUR REFRESHER COURSE FOR THOSE WHO ARE ALREADY LPC SUPERVISORS (9 am to 4 pm with 1 hour lunch off site and on your own)

Print this form, and mail to:

Wellspring Therapy Associates, PLLC 1122 West Blanco, San Antonio, Texas 78232
Or fax to 210-492-2630. Or by telephone 210-490-4540 (voicemail only).
Name ______

Address ______

______

Email: ______

Telephone: ______

I will attend the following Supervisor Training and agree to cancellation and refund policies listed at the bottom of this form. SELECT ONE 2-DAY IN-CLASS 2017TRAINING COURSE OR REFRESHER COURSE:

______February 2 & 3 (OR)

______March 9 & 10 (OR)

______May 11 & 12 (OR)

______July 13 & 14(OR)

______JULY 21 LPC-S 6 HOUR REFRESHER

______August 34 (OR)

______October 12 & 13 (OR)

______November 30 & December 1

Regular Fee: / $525 for 40 hour Supervisor Training
$200 FOR LPC-S SIX-HOUR REFRESHER
"Early Bird"Rate (register full THREE weeks prior for 40 hour training):
Full payment must be received by deadline to receive this rate. / $500 for 40 hour Supervisor Training
$150 FOR LPC-S REFRESHER (2WEEKS PRIOR)
Group Rate (three or more): / $500 for 40 hour Supervisor Training

______TOTAL
VISA, MC, AMEX or Discover# ______
Expiration Date ______Signature ______

*Cancellation or Refund PolicyWellspring Therapy Associates, PLLC reserves the right to change its payment procedures at any time without prior notice (not for registered persons).Prices are in effect for the above training as of May 31, 2017. Prices may change without notice for future trainings.No credit or refund will be issued for registering to take one of our live instruction courses if you do not attend, regardless of date of notice or explanation. However, you will be offered a spot at a future course offered within 12 months of the original course date. Texas Board Rules require the course be completed within 90 days of start date. We will work with you to re-start the course, but a new at-home study guide may need to be purchased. This is complicated if you start the at-home portion and may need to destroy and begin again. OUR BEST ADVICE: DO NOT REGISTER UNLESS YOU ARE SURE YOU CAN ATTEND!