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Please indicate which of the following workshops you wish to attend:

ATS5A on 2/24/12
Stress Management

ATS5B on 2/25/12
Anxiety Disorders

ATS6A on 3/23/12
Overcoming Depression

ATS6B on 3/24/12
Pain Control

ATS7A on 4/27/12
Smoking Cessation

ATS7B on 4/28/12
Weight Control

ATS8A on 5/18/12
Acute Trauma

ATS8B on 5/19/12
Post Traumatic Stress Disorder (PTSD)

ATS9A on 6/15/12
Enhancing Creativity

ATS9B on 6/16/12
Taming The Inner Critic

PRE I on 6/21-24/12
Preceptorship I

PRE II on 9/20-23/12
Preceptorship II

Professional Licensure If you are licensed by your state to diagnose and treat, please list your current license(s) and the state(s) that grant them:

Professional Affiliations List any current hospital, academic, institutional, governmental organizations with which you are affiliated:

Highest AGI training No Prior AGI Training FIGI Completed Level 1 Completed Level 2 Completed Level 3 Completed Certification Completed Faculty Training Completed

Other Training When, where, and from whom did you receive other training in guided imagery?

Clinical Specialties What clinical approaches do you utilize most commonly?

Clinical Focus What special problems do you treat most commonly in clinical practice?

Intentions How and in what capacity do you intend to use your advanced training in IGIsm:

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