Peer Consultation and Training in Psychosexual Therapy with Dr. Sara - Registration Form
Please select which time slot you would like to register for:
First Name *
Your answer
Last Name *
Your answer
Title
Your answer
Gender *
Date of Birth *
MM/DD/YEAR
Your answer
Occupation *
Your answer
Employer *
Your answer
Licence # (if applicable)
Your answer
I would like to receive Continuing Education (CE) points. I am a: *
AASECT CE points required *
Please note that the CE points acquired through this program could be used towards AASECT’s professional certification; however, it is not the only criteria for being an AASECT-certified therapist or counselor. Please visit www.AASECT.org for further information.
Mailing Address *
Your answer
Country of Residence *
Your answer
Home Phone
Your answer
Work Phone
Your answer
Cell Phone *
Your answer
E-mail *
Your answer
Preferred method of contact (for administrative purposes and confirming the meetings) *
Required
How would you like to receive materials of missed sessions, should you need to miss any? *
Required
Do you have any food restrictions? (for refreshments which will be provided) *
If yes, please specify:
Your answer
Have you ever been a part of a psychosexual therapy training before? *
If so, please specify the date, trainer/educator and place:
Your answer
What do you hope to achieve from this consultation group and training? *
Your answer
In what way do you think the consultation group and training will help your personal and professional growth? *
Your answer
What is your preferred method of learning? *
Your answer
How many hours of experience do you have with seeing clients in total? (Couples, sexual difficulties, etc.) *
Your answer
How many hours do you anticipate to have clients with presenting sexual issues? *
Your answer
Will psychosexual therapy be a main focus of your practice in the future? *
Please list languages spoken: *
Your answer
Please specify the predominant language or cultural group you work with/ hoping to work with: *
Your answer
Please let us know of any special needs you may have:
Your answer
Please sign your name here if you consent to e-mail correspondence, which might include personal information: *
Your answer
Payment
You can either pay vıa cheque or credit card.
Credit card: http://www.sara-nasserzadeh.com/wp-content/uploads/2017/10/Credit-Card-Authorization-Form-2017.pdf

Cheque:
Please submit payment via cheque by November 1st.
Amount: $1500
Made payable to:

Sara Nasserzadeh, PhD
467 Hamilton Avenue, suite #5
Palo Alto CA 94301

Cancellation policy
We know life happens but please notify the office of any need for change or cancellation at least two weeks prior to the initial date of the class or 20% course fee will not be refunded.
Venue of the training
Palo Alto CA 94301
Further questions
If you have any further questions please contact Dr. Nasserzadeh’s direct voicemail at (212) 696 6732 or send an email to Rayka Kumru: rayka@sara-nasserzadeh.com
About Dr. Sara
Dr. Nasserzadeh is an Accredited Psychosexual Therapist by the College of Sex and Relationship Therapists in England (COSRT) and a Certified Sexuality Counselor by American Association for Sexuality Educators Counselors and Therapists (AASECT). However, she does not practice in the capacity of a mental health practitioner. By signing this form, you acknowledge the receipt of this information and consent to receive consultations and training from Dr. Nasserzadeh.
www.Sara-Nasserzadeh.com
Print name *
Your answer
Date *
(MM/DD/YEAR)
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms