Workshops in Clinical Hypnosis - University of Minnesota ...

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Workshops in Clinical Hypnosis 2013 June 6 – 8, 2013 Registration Form 3342/DH Please type or print clearly. A name badge and statement of attendance are generated from this form. Name___________________________________________________________________________________________________________________ Affiliation_______________________________________________________________________________________________________________ Department_____________________________________________________________________________________________________________ h HOME h OFFICE Address______________________________________________________________________ Mail Stop_ ________________________________ City_________________________________________________________ State__________________ Zip ____________________________ Office Telephone Number___________________________________________ FAX_________________________________________________ E-mail__________________________________________________________________________________________________________________ Receipts, confirmations, and driving directions are now emailed from our office. Please include your email address and print clearly. Degree h MD h DO h PhD h EdD h MSW/ACSW h LMFT h MA/MS h RN h RT h CNP h DDS/DMD h Other _______________________________________________________ Specialty h Family Medicine / Subspecialty__________________________________________________________________________ h Internal Medicine / Subspecialty_________________________________________________________________________ h Pediatrics / Subspecialty_______________________________________________________________________________ h Radiology / Subspecialty________________________________________________________________________________ h Dentistry h Psychology h Education h Surgery h Psychiatry h Marriage/Family Therapy h Social Work h Other ______________________________________________ Profession I am licensed in_ ___________________________________ State_______________ Lic # _____________________________ REGISTRATION FEES _ _ On or before May 9, 2013 After May 9, 2013 h Full Registration Fee (INTRO or INTER/ADV) _ _ _ $510_ _ _ $550 h MSCH Member _ _ _ $400__ _ _ $440 h Radiologic Technician (RT)/ASRT Member (applies to INTER/ADV only) $325__ _ _ $325 h Graduate Student _ _ _ $325__ _ _ $325 h Speaker/Faculty _ _ _ $260__ _ _ $275 University of Minnesota h U of MN Full-time Faculty _ _ _ $400_ _ _ $440 h U of MN Adjunct Faculty _ _ _ $400_ _ _ $440 h U of MN Resident/Fellow/Graduate Student _ _ _ $325_ _ _ $325 GROUP REGISTRATION A minimum of 3 registrants from the same organization is required for a group discount of $20 per person to be deducted from the _ corresponding registration fees listed above. Submit all registrations together with one check payment. NO refunds will be issued if a _ person from a group has to cancel or does not show up at the conference. Normal refund policy applies for complete group cancellations. Special Needs: Special needs such as dietary restrictions should be indicated in advance; requests cannot always be honored on site. Dietary: ___________________________________________________________ Other:_ ______________________________________________ WORKSHOP REGISTRATION (Check the workshop section you plan to attend and then select one session.) Introductory Workshop - Select ONE Integrating Hypnosis into Practice session for Saturday, June 8, 4:45–6:00 pm. h Child Health: Medical and Behavioral h Psychotherapy h Integrated Care: Medical and Mental Health h Acute and Chronic Pain Intermediate/Advanced Workshop - Select ONE of the Small Group Seminars, Tutorials, & Practice sessions on _ Thursday, June 6, 7:00 – 9:15 pm. h Advanced Hypnosis Techniques: Reviewing the Work of the Masters h Hypnosis as a Hypnotic: Trance and the Treatment of___ h Hypnosis and Psychotherapy: Getting Started and Continuing On_ _ Sleep Disorders_ h New Developments in Brain-Body Interactions: How to Integrate h Storytelling – When, Why, How Hypnosis into Treatment h Biofeedback and Hypnosis with Children and Teenagers CANCELLATION POLICY In the event you need to cancel your registration, the registration fee, less a $50 administrative fee, will be refunded if you notify us _ by 4:30 p.m. CST on May 23, 2013. No refunds will be made after this date. Mail this registration form and your check, payable to The Regents of the University of Minnesota, to: _ Clinical Hypnosis, Office of CME, University of Minnesota, University Park Plaza, _ 2829 University Avenue SE, Suite 901, Minneapolis, MN 55414 If you have any questions, please contact our office at (612) 626-7600, (800) 776-8636, or e-mail us at cme@umn.edu.
Host Workshop Faculty Guest Faculty ELVIRA LANG, MD, Author, Patient Sedation Without Medication; Founder and President, Hypnalgesics, LLC; former Associate Professor of Radiology, Harvard University and University of Iowa Host Faculty *RONI J. AHERN, MA, LP, Private Practice, Minneapolis; ASCH Approved Consultant in Clinical Hypnosis; Small Group Coordinator for MSCH Workshops in Clinical Hypnosis *ANDREW J. BARNES, MD, MPH, Assistant Professor, Pediatrics and Adolescent Health, Developmental-Behavioral Pediatrics, University of Minnesota, Minneapolis, MN; Former physician member-at-large, MSCH; ASCH Approved Consultant in Clinical Hypnosis Cheryl S. Bemel, PhD, LP, Licensed Psychologist; Nationally Certified School Psychologist (NCSP); MSCH Treasurer; Staff Psychologist, Allina Health BETSY SHRYER BOYLE, PsyD, LP, Private Practice, St. Paul, MN SUZANNE CANDELL, PhD, LP, Private Practice, Minneapolis; Clinical Health Psychologist, Minnesota Head and Neck Pain Clinic, St. Paul; Former MSCH Board Member; ASCH Approved Consultant in Clinical Hypnosis BEVERLY CARUSO, LICSW, MSW, Therapist, Private Practice, Minneapolis ALFRED L. CLAVEL, JR., MD, Adjunct Associate Professor of Neurology, University of Minnesota Medical School; Director, Pain Rehabilitative Services, Pain and Palliative Care Center, Fairview University Medical Center, Minneapolis; MSCH Past President Scott Cruse, MSW, LICSW, Psychotherapist, Regions Hospital Cancer Care Center, Saint Paul, MN; MSCH board member DENISE D’AURORA, MEd, LP, LMFT, Private Practice, Edina, MN and St. Paul, MN RICHARD DUUS, PhD, Duluth Psychological Clinic, Duluth; ASCH Approved Consultant in Clinical Hypnosis MARK FASTNER, MA, LP, Counseling and Psychological Services; Licensed Psychologist; Outpatient Psychotherapy and Chemical Dependency, Regions Hospital, St. Paul, MN; ADAP MARY FREITAG PsyD, LP, Clinical Psychologist and Supervisor, Integrative Psychological Services, St. Paul, MN DIXIE GRACE, PhD, LP, Staff Psychologist, VA Medical Center, Minneapolis, MN *MARY GROVE, PsyD, LP, Psychologist, Allina Health, West St. Paul; MSCH Board Secretary; Coordinator, Introductory Workshop GREG HEBERLEIN, MA, LP, Private Practice, St. Paul and Stillwater, MN DELLE JACOBS, MSW, LICSW, LMFT, Private Practice, St. Paul, MN REBECCA KAJANDER, MPH, BSN, CNP, Noran Neurological Clinic, Minneapolis, MN *DANIEL P. KOHEN, MD, Director, Developmental-Behavioral Pediatrics; Professor, Departments of Pediatrics and Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis; MSCH Director of Education and Training; MSCH Past President; Past President, American Board of Medical Hypnosis; Vice-President ASCH (2011-2012), ASCH Approved Consultant in Clinical Hypnosis; Course Director MICHAEL LaCROSSE, PhD, LP, Private Practice, Norfolk, NE; ASCH Approved Consultant in Clinical Hypnosis; Fellow, American Psychological Association (Division 17-Counseling Psychology, Division 42–Psychologists in Independent Practice); Member, National Register of Health Service Providers in Psychology; MSCH Member WENDY K. LEMKE, MS, LP, Clinical and consulting practice, Clearwater and Brooklyn Park, MN; Part-time faculty, St. Cloud Technical Community College; ASCH Vice-President; ASCH Approved Consultant; Former MSCH Board Member; Member and Fellow of the International Society for the Study of Trauma and Dissociation JEAN S. MANLOVE , MSW, ACSW, LICSW, LCSW-C, Private mental health practice. Adjunct faculty, George Mason University, Fairfax, VA. Past MSCH Board Member. Approved Consultant in Clinical Hypnosis- ASCH. RALPH E. McKINNEY, PhD, FASCH, LP, Private Practice, Journey Counseling Center, Minnetonka, MN; Director of Pain Management Program, Vinland National Center, Loretto, MN; ASCH Certified Hypnosis Consultant; Diplomate, American Academy of Pain Management; ASCH Past Executive Board Member; MSCH Past President *SHEPHERD R. MYER, PhD, LP, Health Psychologist, Fairview Pain Center, University of Minnesota Medical Center; Adjunct Professor, American School of Professional Psychology; MSCH President; Coordinator, Introductory Workshop HELEN C. PAUL, PhD, LP, Private Practice, Minneapolis; MSCH Past President and Treasurer; ASCH Approved Consultant in Clinical Hypnosis *TERESA QUINN, MD, Assistant Professor, Family Medicine Residency, Park Nicollet Methodist Hospital, St. Louis Park, MN; Diplomate, American Board of Medical Hypnosis JACK S. RUSINOFF, MA, Licensed Psychologist, Minnesota Department of Corrections; ASCH Certified in Clinical Hypnosis; MSCH Former Board Member PEGGY TREZONA, MS, RN, CS, Psychotherapist, Private Practice, St. Paul; MSCH Past President DAVID WARK, PhD, ABPH, Emeritus Professor of Psychology, University of Minnesota; Diplomate, American Board of Psychological Hypnosis, MSCH Past president; ASCH Past President, Fellow ASCH, SCEH, Independent private practice MARK B. WEISBERG, PhD, ABPP, LP, Clinical Health Psychologist, Diplomate in Health Psychology, American Board of Professional Psychology; Listed, National Register of Health Service Providers in Psychology; Independent Practice, Minneapolis; MSCH Past President; ASCH Approved Consultant in Clinical Hypnosis; Fellow, Past Vice President, ASCH ELAINE WYNNE, MA, LP, Licensed Psychologist in Private Practice, Minneapolis, MN; Former Faculty, Metropolitan State University, Minneapolis, MN; Past Board Member, MSCH; Approved Consultant, ASCH * Denotes Planning Committee Member
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Page 3 and 4: WORKSHOP LOCATION & OVERNIGHT ACCOM
Page 5: Intermediate/Advanced Workshop Gues

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