November 18, 2016 Life Story Board Workshop Registration

Contact Information and Background

LSB Basic Workshop Friday Novemebr 18, 2016
• light lunch provided, or bring your own, kitchenette is available
• Includes digital copies of background materials and web links
• Workshop is limited to 8 participants max.

Registration Deadline November 14, 2016

Payment Options: PayPal, credit card online, or by cheque / credit card at time of workshop. On registration you will be emailed an invoice with link for online payment. Please review your invoice details and payment.

Contact Rob Chase MD if you have any questions: 204-232-4870; rob.chase@vidaview.ca

Purchase of the Life Story Board Toolkit

Special 30% workshop discount $245 +GST (regular price $350)
Purchase not necessary for workshop, LSB Kits can be purchased at discount price after workshop; shipping charges may apply.

includes invitation to join Vidaview's ‘LSB Introduction' Basecamp project to access resources and updates, share questions and observations on a secure private discussion forum.

After Care and Supervision: One-on-one time with a LSB Trainer by skype, Zoom, phone, in-person can be arranged.
A self-directed 'After Care' package builds basic LSB 'literacy' and skill, with reading materials, A/V case studies, practice exercises, session rehearsal, e.g. a few hours/ week of play and practice over a month. The LSB trainer / supervisor facilitates familiarization with LSB as you develop your comfort and approach preparatory to clinical use. A secure LSB Aftercare discussion forum to share questions, comments and experiences and photos of LSB scenarios.

Question Title

* 1. Please provide the following information. Please note: 'Name' 'City/Town' 'Country' and 'Email Address' are REQUIRED fields and must be completed before you will be able to proceed to the next page.

Name: *

Organization:

Address 1:

City/Town:

State/Province:

ZIP/Postal Code:

Country:

Email Address: *

Phone Number:

Question Title

* 2. Please describe your experience and training background.

Degrees:

Certification:

Licensure:

Practice Approach, Theory, or School:

Years in Practice:

Other Relevant Experience:

Question Title

* 3. Please describe your type of practice and clinical/community setting.
Check boxes that apply and describe in the comment box.

	Children	Family	Youth	Adults	Elderly	First Nations/ Aboriginal/ Metis	Multicultural
Private Practice	Private Practice Children	Private Practice Family	Private Practice Youth	Private Practice Adults	Private Practice Elderly	Private Practice First Nations/ Aboriginal/ Metis	Private Practice Multicultural
In a Primary Health Care Organization	In a Primary Health Care Organization Children	In a Primary Health Care Organization Family	In a Primary Health Care Organization Youth	In a Primary Health Care Organization Adults	In a Primary Health Care Organization Elderly	In a Primary Health Care Organization First Nations/ Aboriginal/ Metis	In a Primary Health Care Organization Multicultural
In a Mental Health Agency	In a Mental Health Agency Children	In a Mental Health Agency Family	In a Mental Health Agency Youth	In a Mental Health Agency Adults	In a Mental Health Agency Elderly	In a Mental Health Agency First Nations/ Aboriginal/ Metis	In a Mental Health Agency Multicultural
Detention/Prison Services	Detention/Prison Services Children	Detention/Prison Services Family	Detention/Prison Services Youth	Detention/Prison Services Adults	Detention/Prison Services Elderly	Detention/Prison Services First Nations/ Aboriginal/ Metis	Detention/Prison Services Multicultural
In a Community Program	In a Community Program Children	In a Community Program Family	In a Community Program Youth	In a Community Program Adults	In a Community Program Elderly	In a Community Program First Nations/ Aboriginal/ Metis	In a Community Program Multicultural
Child and Family Services	Child and Family Services Children	Child and Family Services Family	Child and Family Services Youth	Child and Family Services Adults	Child and Family Services Elderly	Child and Family Services First Nations/ Aboriginal/ Metis	Child and Family Services Multicultural
Other	Other Children	Other Family	Other Youth	Other Adults	Other Elderly	Other First Nations/ Aboriginal/ Metis	Other Multicultural

Please describe

Question Title

* 1. Please provide the following information. Please note: 'Name' 'City/Town' 'Country' and 'Email Address' are REQUIRED fields and must be completed before you will be able to proceed to the next page.

Question Title

* 2. Please describe your experience and training background.

Question Title

* 3. Please describe your type of practice and clinical/community setting. Check boxes that apply and describe in the comment box.

* 3. Please describe your type of practice and clinical/community setting.
Check boxes that apply and describe in the comment box.