3314610 Attestation - Attachment Conference

1. Attendance Verification and Certificate Request

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The AMA requires that the number of credits listed on CME certificates be based on the actual credit claimed by each physician. You will need to fill out the below questions in order to receive your CME certificate. Your certificate will be emailed to you 2-3 weeks after the survey is completed.

There are several continuing education certificates available, please pay close attention to the next two pages and select carefully from our professional certificate options: Physicians, Psychologists, Social Workers, Licensed Mental Health Counselors and Nurses * Questions with an asterisk are required before evaluation can be submitted.

*Questions with an asterisk are required before evaluation can be submitted.

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* 1. YOUR NAME FOR CERTIFICATE: Please type your name how you would like it to appear on your certificate.
*THIS QUESTION REQUIRES AN ANSWER

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* 2. Your Degree
*THIS QUESTION REQUIRES AN ANSWER

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* 3. Your Email address for Certificate:
(Please submit email address you want your CME certificate/credit sent to.)
*THIS QUESTION REQUIRES AN ANSWER

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* 4. Select the type(s) of non-physician continuing education credits you require:

American Psychological Association (APA) continuing education units (must have attended the entire course).

National Board for Certified Counselors (NBCC) clock hours (please fill our the tracking form in Question 44).

Nursing continuing education units

National Association of Social Worker (NASW) contact hours (must have attended the entire course)

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* 5. If you are requesting accredited clock hours from the National Board of Certified Counselors (NBCC), please electronically attest to each session you attended:

(Day One Sessions: October 25th, 2013): Welcome and Introduction - John G. Gunderson, MD; Peter Fonagy, PhD, FBA; Christopher M. Palmer, MD (15 minutes)

How Therapy Works: The Voice of Babies - Peter Fonagy, PhD, FBA - (60 minutes)

Transference-Focused Psychotherapy and Early Relationships - Otto F. Kernberg, MD, FAPA (60 minutes)

Developmental Biology of Bonding - Linda C. Mayes, MD (60 minutes)

Morning Speakers Discussion Panel, Moderated by Lois W. Choi-Kain, MD, MEd (45 minutes)

Toward a Functional Neuroanatomy of BPD - David A. Silbersweig, MD (60 Minutes)

Behavioral, Biological, and Epigenetic Consequences of Differences in Early Attachment Relationships in Primates - Stephen J. Suomi, PhD (60 Minutes)

Attachment, Temperament, and Neural Integration in the Development of Personality - Daniel J. Siegel, MD (60 minutes)

Afternoon speakers - Discussion Panel, Moderated by Scott L. Rauch, MD (60 Minutes)

Day Two Sessions: October 26th, 2013 The Emerging Adolescent Mind and the Changing Teenage Brain - Daniel J. Siegel, MD (60 Minutes)

Disorganized Attachment: Its Developmental Consequences and Implications for Psychotherapy - Karlen Lyons-Ruth, PhD (60 minutes)

Interpersonal Hypersensitivity: BPD’s Core - John G. Gunderson, MD (60 minutes)

Morning Speakers Discussion Panel - Moderated by Mary C. Zanarini, EdD (60 minutes)

A Psycho-evolutionary Perspective on the Structure of BPD - John W. Livesley, MD, PhD (60 minutes)

A MBT Perspective - Anthony W. Bateman, MA, FRCPsych (60 Minutes)

A DBT Perspective - Marsha M. Linehan, PhD (60 minutes)

Afternoon Speakers Discussion Panel, Moderated by Robert J. Waldinger, MD (30 minutes)

SUNDAY October 27th, 2013 - Optional Workshop I: Good Psychiatric Management Workshop, John G. Gunderson, MD and Lois w. Choi-Kain, MD, MEd (180 minutes)

SUNDAY October 27th, 2013 - Optional Workshop II: Mentalization Based Treatment (MBT) for Borderline Personality Disorder: Introduction to Clinical Practice - Peter Fonagy, PhD, DipPsy, FBPSA, FBA, Anthony W. Bateman, MA, FRCPsych - (180 minutes)

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* 6.
ACCREDITATION STATEMENT

The Harvard Medical School is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Designation Statement:
The Harvard Medical School designates this live activity for a maximum of 17.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
If you are applying for credits for Sunday's optional workshops please make sure second evaluation is also completed in order to receive full credit.

Course Credit Breakdown:
Course only: a maximum of 14.50 AMA PRA Category 1 Credits™.

Course with Sunday morning sessions: a maximum of 17.50 AMA PRA Category 1 Credits™.

If you did not attend every session please use the session listing below to help calculate your total credits/hours to be awarded.

Friday - morning sessions (3.75 credits/hrs)

Friday - afternoon sessions (3.50 credits/hrs)

Saturday - morning sessions (3.75 credits/hrs)

Saturday - afternoon sessions (3.50 credits/hrs)

Sunday optional workshops - (3.0 credits/hrs)

How many credits will you be claiming?
*THIS QUESTION REQUIRES AN ANSWER

Question Title

* 1. YOUR NAME FOR CERTIFICATE: Please type your name how you would like it to appear on your certificate.*THIS QUESTION REQUIRES AN ANSWER

Question Title

* 2. Your Degree*THIS QUESTION REQUIRES AN ANSWER

Question Title

* 3. Your Email address for Certificate: (Please submit email address you want your CME certificate/credit sent to.) *THIS QUESTION REQUIRES AN ANSWER

Question Title

* 4. Select the type(s) of non-physician continuing education credits you require:

Question Title

* 5. If you are requesting accredited clock hours from the National Board of Certified Counselors (NBCC), please electronically attest to each session you attended:

Question Title

ACCREDITATION STATEMENT

* 1. YOUR NAME FOR CERTIFICATE: Please type your name how you would like it to appear on your certificate.
*THIS QUESTION REQUIRES AN ANSWER

* 2. Your Degree
*THIS QUESTION REQUIRES AN ANSWER

* 3. Your Email address for Certificate:
(Please submit email address you want your CME certificate/credit sent to.)
*THIS QUESTION REQUIRES AN ANSWER