Pediatric Clinical Hypnosis Skill Development Workshops 2012 presented by September 20–22, 2012 Crowne Plaza Hotel Minneapolis West(formerly Radisson Hotel and Conference Center Minneapolis) 3131 Campus Drive Plymouth, Minnesota In Collaboration with Minnesota Society of Clinical Hypnosis University of Minnesota Department of Pediatrics
CouRSe DeSCRiPtionClinical Hypnosis is a therapeutic intervention with empirical support for a variety of clinical conditions: includingprocedure-related and chronic pain, anxiety disorders, stress-related conditions, habit problems, sleep disturbance, andvarious medical conditions. This workshop provides training in the use of clinical hypnosis and its applications to childrenand teens with various conditions in pediatric settings. The workshop is offered at three levels (Introductory, Intermediateand Advanced) depending on the clinician’s previous training in pediatric hypnosis. Strong emphasis is placed onexperiential learning, with supervised practice of hypnotic techniques suitable for children/teens and of integrating adevelopmental perspective.eligibility anD taRget auDienCeThese workshops would be ideal for persons holding a:• Doctoral Degree in Medicine, Psychology, or Dentistry• Masters Degree in Social Work, Marriage and Family Therapy, Clinical or Counseling Psychology• Masters Degree in Nursing or a Registered Nurse with subspecialty training and certification• Other Advanced degree health care providers, e.g. Occupational and Physical Therapists, Speech and Language Pathologists, et. al.• Child Life Specialists holding a Bachelor’s degree• Students, Interns, Residents and Fellows actively enrolled in a graduate program leading to degrees or completion of training in any of the foregoing.intRoDuCtoRy WoRkSHoPThis workshop teaches basic skill-building in hypnosis as a therapeutic intervention for children/teens experiencing avariety of clinical conditions. Particular focus is on management of pain, anxiety, and sleep. Instructional videotapes andcase vignettes are an integral component of presentations. Experiential learning is strongly emphasized (this workshopprovides almost double the amount offered in most introductory hypnosis workshops), including group exercises andsupervised small group practice focused on the structure and elements of clinical hypnosis with children/teens. Thisworkshop is for those without prior pediatric-specific hypnosis training.RegiStRationRegistration Deadlines & FeesIntroductory and Intermediate Workshops. Register by August 23, 2012 to receive the Early Registration Discount! On or before August 23, 2012 After August 23, 2012Registration Fee $695 $795MSCH Member $610 $690Graduate Student/Intern/Resident/Fellow/Trainee $550 $575To Register for the Introductory WorkshopONLINE: Register online with Visa, MasterCard, or American Express at www.cme.umn.edu/intropedshypnosisinfo. Inorder to protect your credit card information, the Office of Continuing Medical Education (OCME) does not accept creditcard payments by phone, fax, mail, in person, or on-site.BY MAIL: Mail your check (payable to Regents of the University of Minnesota) with registration form to: Pediatric ClinicalHypnosis, Office of Continuing Medical Education, University of Minnesota, University Park Plaza, Suite 601, 2829University Avenue SE, Minneapolis, MN 55414.inteRMeDiate WoRkSHoPThe focus in this workshop is on refining and expanding existing hypnosis skills in broader clinical applications, andfurthering assessment and individualized treatment approaches for patients and their families. Clinical videotapes andcase vignettes are integral components of presentations. Participants must have prior pediatric-specific hypnosis trainingand experience in using clinical hypnosis with pediatric patients. Completion of a Prior Learning/Needs Assessmentquestionnaire is required prior your registration being accepted for this workshop. This is not a beginning level course.
RegiStRationRegistration Deadlines & FeesIntroductory and Intermediate Workshops. Register by August 23, 2012 to receive the Early Registration Discount! On or before August 23, 2012 After August 23, 2012Registration Fee $695 $795MSCH Member $610 $690Graduate Student/Intern/Resident/Fellow/Trainee $550 $575To Register for the Intermediate WorkshopClick on the words Prior Learning/Needs Assessment or www.cme.umn.edu/interpedshypnosisinfo to access and completethe assessment. Upon acceptance of your assessment, you will be contacted with registration instructions.aDvanCeD WoRkSHoPThe Advanced Workshop will provide individualized mentor consultation to health and mental health care practitionersinterested in enhancing their knowledge and expertise in the use of pediatric hypnosis. This 22-hour intensive meeting isdesigned to fulfill the requirements for attaining ASCH Certification in Clinical Hypnosis and/or to obtain the hours ofconsultation necessary to become an ASCH-Approved Consultant. In addition to providing evidence of previous trainingand regular use of pediatric hypnosis in their clinical practice, advanced participants must bring and present a DVD orVHS videotape of hypnotic work with a pediatric patient and a corresponding typed case vignette of the video. Thedeadline for video submission is July 15, 2012. We will provide a "how to" guide to help learners develop effective videorecordings. Completion of a Prior Learning/Needs Assessment questionnaire is required before your registration will beaccepted for this workshop.Individuals attending this program must have completed an ASCH-Approved Pediatric Introductory (Basic) and PediatricIntermediate Workshop (such as NPHTI 2010 or 2011 or those previously taught by this faculty via the Society ofDevelopmental and Behavioral Pediatrics) and should be using hypnosis regularly in their professional practice. The formatis unique and one in which participants meet and consult in a small group setting with fellow practitioners and a group offacilitators who are ASCH Approved Consultants. This model encourages and expects participants to learn from oneanother, to have their own expertise affirmed and expanded, and to network with other professionals in pediatric clinicalhypnosis. During the consultation sessions the focus is upon issues unique to each practitioner’s specialties and practice.RegiStRationRegistration Deadlines & Fees On or before July 15, 2012 Registrations will not be acceptedAdvanced Workshop Registration Fee $850 after July 15, 2012To Register for the Advanced WorkshopClick on the words Prior Learning/Needs Assessment or www.cme.umn.edu/advpedshypnosisinfo to access and complete theassessment. Upon acceptance of your assessment, you will be contacted with registration and video submission instructions,and a “how to” guide to developing effective video recordings. Please note video submissions are due by July 15, 2012.Registration fees for all three workshops include course presentations on CD, breakfast and lunch buffets, and morning andafternoon refreshments. Special needs such as dietary restrictions should be indicated in advance; requests cannot always behonored on site.Note: Participants are not considered registered until registrant information and payment have been received by our office.Group RegistrationA minimum of 3 registrants is required for a group discount of $20 per person to be deducted from the corresponding registrationfee listed above. Submit all registrations together with one check payment. NO refunds will be issued if a person from a grouphas to cancel or does not show up at the conference. Normal refund policy applies for complete group cancellations.Course MaterialsA CD with a PDF of the course presentations will be available to attendees and distributed at the Workshop. A printedsyllabus will NOT be distributed at the Workshop. Registered attendees will be emailed access instructions to view thepresentations online prior to the Workshop; and download or print for their use at the conference. Please note: NO servicesfor printing syllabi are available on site during the conference.
Cancellation PolicyIn the event you need to cancel your registration, the registration fee, less a $50 administrative fee, will be refunded if younotify us by 4:30 p.m. Central Time on September 6, 2012. No refunds will be made after this date.WoRkSHoP loCation & oveRnigHt aCCoMMoDationSCrowne Plaza Hotel Minneapolis West3131 Campus Drive, Plymouth, MN 55441Phone: 763-559-6600Web site: http://cpplymouth.com/A block of hotel rooms is available at the discounted rate of $99.00 plus the current 7.275% tax. Please make yourreservations directly with the hotel by the cut-off date of August 29, 2012, and refer to the course by name to receive thediscounted rate. Reservations will be accepted on space and rate availability. Parking is complimentary and adjacent to theconference center.aCCReDitationamerican Medical association/PRaThis activity has been planned and implemented in accordance with the Essential Areas and policies of the AccreditationCouncil for Continuing Medical Education (ACCME) through joint sponsorship of the University of Minnesota, the NationalPediatric Hypnosis Training Institute and the Minnesota Society of Clinical Hypnosis. The University of Minnesota isaccredited by the ACCME to provide continuing medical education for physicians.The University of Minnesota designates this live activity for a maximum of 23.5 AMA PRA Category 1 Credits™ for theintroductory Workshop, 23.0 AMA PRA Category 1 Credits™ for the intermediate Workshop and 22.0 AMA PRA Category1 Credits™ for the advanced Workshop. Physicians should claim only the credit commensurate with the extent of theirparticipation in the activity.American Academy of Family PhysiciansApplication for AAFP credit has been filed with the American Academy of Family Physicians. Determination of credit ispending.American Society of Clinical HypnosisApplication has been made to the American Society of Clinical Hypnosis Standards of Training Committee for approval ofcredit hours toward the Certification and Approved Consultant requirements.Minnesota Board of Marriage and Family TherapyAn application for credit has been submitted to the Minnesota Board of Marriage and Family Therapy.Minnesota Board of Social WorkThis activity has been approved by the State of Minnesota Board of Social Work for 23.5 continuing education hours for theIntroductory Workshop, 23 continuing education hours for the Intermediate Workshop, and 22 continuing education hoursfor the Advanced Workshop.Dentists, Nurse Practitioners, Nurses, and Other Health Care ProfessionalsDentists, nurse practitioners, nurses, and other health care professionals who participate in this CME activity may submittheir Statements of Attendance to their appropriate accrediting organizations or state boards for consideration of credit. Theparticipant is responsible for determining whether this activity meets the requirements for acceptable continuing education.ADDITIONAL TYPES OF CREDIT HAVE BEEN APPLIED FOR AND WILL BE UPDATED ON THE WEB SITE WHEN APPROVED.DiSCloSuRe PoliCyIt is the policy of the University of Minnesota office of Continuing Medical Education to ensure balance, independence,objectivity and scientific rigor in all of its sponsored educational activities. To review the complete Disclosure Policy visitwww.cme.umn.edu/disclosure.
intRoDuCtoRy WoRkSHoP educational objectives At the completion of the Introductory Workshop, participants will be better able to: • List the stages of hypnosis • Describe hypnosis as a process of therapeutic communication • Describe and demonstrate four pediatric hypnosis induction methods • Identify four developmental considerations influencing hypnotic techniques • Describe a hypnotic method for intensification, suggestions, utilization and talking in trance • Describe the processes of re-alerting and debriefing • List four applications for pediatric hypnosis • Describe and demonstrate, for each situation, a hypnotherapeutic approach for children experiencing procedural pain, chronic and recurrent pain, clinical anxiety and sleep disturbance • Outline a strategy for getting started using hypnosis in clinical practice PReliMinaRy agenDathursday, September 20 11:50 lunch buffet 7:15 aM Registration & breakfast buffet 1:05 PM Q&A 8:00 Introduction & CME Overview (All Groups) 1:15 Clinical Applications: Anxiety 8:05 Introduction to Workshop: Overview and Self-Regulation (All Groups) 2:20 Clinical Applications: Sleep 8:30 Introduction to Hypnosis: Definitions, 3:15 Refreshment break Theories, Myths & Misconceptions, 3:35 Contextualization: Talking in Trance/Treatment Uses, Susceptibility Planning/Post-Hypnotic Suggestions 9:15 Hypnosis: Structure & Stages 4:20 #4 Induction & Intensification: The Breath10:00 Refreshment break 4:40 Small Group Practice #4: Rapport,10:20 Hypnosis: The Many Right Ways Induction, Suggestion, Talking in Trance,11:00 Developmental Considerations: Designing Post-Hypnotic Suggestions, Alert, Debrief Hypnosis Sessions 6:00 adjourn for the Day11:55 Hypnotic Induction/Intensification Evening Optional Viewing (on own) of Videotapes Techniques: Overview12:15 PM lunch buffet Saturday, September 22 1:30 #1 Induction & Intensification: 7:15 aM breakfast buffet Dissociation (Special Place) 8:00 Pain: Principles, Acute & Procedural Pain 1:50 Small Group Practice #1: Rapport, 9:00 Self-Hypnosis: Learning/Teaching Induction, Intensify, Alert, Debrief 9:20 Self-Hypnosis: Faculty Mini-Demos 3:20 Refreshment break 9:30 Self-Hypnosis: Large Group/Debrief 3:40 #2 Induction & Intensification: Eye Roll 10:00 Refreshment break 4:00 Small Group Practice #2: Rapport, 10:20 Small Group Practice #5: Rapport, Induction, Intensify, Alert, Debrief Induction, Intensify, Self-Hypnosis, Post- 5:30 Ethics & Professional Conduct (All Groups) Hypnotic Suggestions, Alert, Debrief 6:00 History of Hypnosis 12:00 PM lunch buffet (included) 6:15 adjourn for the Day 1:15 Small Group Practice #6: Putting It All Evening Optional: Viewing (on own) of Videotapes Together 2:45 Refreshment breakFriday, September 21 3:05 Hypnosis in Your Work Setting 7:15 aM breakfast buffet (with Intermediate Group) (select one): 8:00 Introducing Hypnosis to Patients & Parents/ 1) Primary Care Utilization of Parents 2) Anxiety 8:45 Formulating Suggestions: Language & 3) Pain/Procedural Stress/Distress Utilization 4) Chronic Illness 9:45 #3 Induction & Intensification: Demo 4:10 Organizations, Ongoing Education, and Ideomotor Magnet Fingers + Utilization Getting Started (with Intermediate Group)10:00 Refreshment break 4:40 Q&A with Faculty (All Groups)10:20 Small Group Practice #3: Induction- 4:45 Conference Summary Intensification: Language & 5:00 adjourn Suggestions-Utilization
inteRMeDiate WoRkSHoPeducational objectives At the completion of this Intermediate Workshop, participants will be better able to: • Refine therapeutic listening and language skills in “finding the hypnosis in the encounter” • Improve competence in tailoring the hypnotic approach to match the child’s developmental level • Expand skills in hypnotic techniques and treatment planning • Enhance ability - apply hypnotic strategies in broader clinical situations, e.g. chronic illness, acute and chronic pain, palliative care, anxiety, habits, sleep problems, and elimination disorders • Perform with competence and confidence in teaching children and families self-hypnosis skills PReliMinaRy agenDathursday, September 20 1:15 Hypnosis for the Treatment of Young 7:15 aM Registration & breakfast buffet People with Acute Pain 8:00 Introduction & CME Overview 2:15 Hypnosis for the Treatment of Young (All Groups) People with Chronic Pain 8:05 Introduction to Workshop: Overview 3:15 Refreshment break (All Groups) 3:35 Small Group Practice #5: 8:35 Hypnosis Principles - Utilization/Treatment Hypnosis for Pain Management Agenda has changed. Planning 5:15 Chronic Illness 9:05 Therapeutic Language & Communication: 6:00 adjourn for the Day Talking in Trance & PHS Evening Optional: Viewing (on own) of Videotapes 9:35 Resistence vs. Readiness Saturday, September 22See website for updates!10:00 Refreshment break10:20 Small Group Practice #1: 7:15 aM breakfast buffet Utilization and Communication 8:00 Children with Disabilities11:40 Teaching Self-Hypnosis 8:45 Hypnosis and Physiologic Challenges12:00 PM lunch buffet 10:15 Refreshment break 1:15 Supervised Small Group Practice #2: 10:35 Seriously Ill Children & Palliative Care Self-Hypnosis 11:15 Integrative Approaches: Biofeedback 2:30 Creating Metaphors in Pediatrics Emphasis 3:15 Refreshment break 12:15 PM lunch buffet 3:35 Supervised Small Group Practice #3: 1:30 Supervised Small Group Practice #6: Creating Metaphors Biofeedback 4:50 Children’s Style Patterns: Developmental 2:45 Refreshment break Aspects 3:05 Hypnosis in Your Work Setting (with 5:30 Ethics and Professional Conduct Introductory Group) (select one) (All Groups) 1) Primary Care 6:00 adjourn for the Day 2) Anxiety Evening Optional: Viewing (on own) of Videotapes 3) Pain/Procedural Stress/Distress 4) Chronic IllnessFriday, September 21 4:10 Organizations, Ongoing CE, & Going 7:15 aM breakfast buffet Further (with Introductory Group) 8:00 Ericksonian Stategies 4:40 Q&A with Faculty (All Groups) 9:00 Anxiety, Worry, Fear: Self-Regulation 4:45 Conference Summary Approaches 5:00 adjourn10:15 Refreshment break10:35 Small Group Practice #4: Ericksonian Approaches12:00 PM lunch buffet
aDvanCeD WoRkSHoP individualized Consultation educational objectives At the completion of this Advanced Workshop, participants will be better able to: • Evaluate one’s own clinical skills and the use of therapeutic language (through video review, critique, and discussion) in context of peer review and individualized consultation with mentor(s) • Problem-solve challenging clinical situations applying hypnotic strategies • Review, evaluate, and offer guidance regarding (others’) clinical hypnosis encounters in mentor- facilitated small group peer consultation context • Delineate and evaluate one’s selection of targeted, specific goal(s) for the videotaped hypnosis session within the larger context of treatment planning PReliMinaRy agenDathursday, September 20 3:35 Continuation of Case Presentation with 7:15 aM Registration & breakfast buffet Mentor Consultation 8:00 Introduction & CME Overview 6:15 adjourn for the Day (All Groups) Evening Optional: Viewing (on own) of Videotapes 8:05 Introduction to Workshop: Overview (All Groups) Saturday, September 22 8:35 Case Presentation with Mentor 7:15 aM breakfast buffet Consultation 8:00 Case Presentation with Mentor10:00 Refreshment break Consultation10:20 Continuation of Case Presentation 10:10 Refreshment break with Mentor Consultation 10:30 Continuation of Case Presentation with12:15 PM lunch buffet Mentor Consultation 1:30 Case Presentation with Mentor 12:15 PM lunch buffet or viewing of videotapes Consultation 1:45 Case Presentation with Mentor 3:20 Refreshment break Consultation 3:40 Continuation of Case Presentation 2:40 Refreshment break with Mentor Consultation 3:00 Continuation of Case Presentation with 5:30 Ethics and Professional Conduct Mentor Consultation (All Groups) 4:45 Q&A with Faculty (All Groups) 6:00 adjourn for the Day 5:00 adjourn Evening Optional: Viewing (on own) of VideotapesFriday, September 21 7:15 aM breakfast buffet 8:00 Conversation with New Facilitators from Around the World! 8:45 Case Presentation with Mentor Consultation10:15 Refreshment break10:35 Continuation of Case Presentation with Mentor Consultation12:00 PM lunch buffet or viewing of videotapes 1:30 Case Presentation with Mentor Consultation 3:15 Refreshment break
HoSt WoRkSHoP FaCulty anD gRouP FaCilitatoRSTIMOTHY P. CULBERT, MD, FAAP, ABMH, BCB LEORA KUTTNER, PHD*Assistant Professor and Clinical Faculty, Department of Pediatrics, Clinical Psychologist and Clinical Professor of Pediatrics,University of Minnesota Medical School, Minneapolis, MN; University of British Columbia and British Columbia Children’sAdjunct Faculty, Center for Spirituality and Healing, University Hospital, Vancouver, Canada; Vice-President, Canadian Societyof Minnesota, Minneapolis, MN; Medical Director, Pediatric of Clinical Hypnosis (BC Division)Integrative Medicine, Ridgeview Medical Center, Minneapolis, MN KAREN OLNESS, MD, FAAP, ABMH*CANDACE J. ERICKSON, MD, FAAP, MPH* Professor of Pediatrics, Family Medicine, and Global Health, CaseCourse Director SDBP Clinical Hypnosis Workshops (1987-2009); Western Reserve University, Cleveland, OH; Diplomate and Past-Associate Professor of Clinical Pediatrics, Columbia University President, American Board of Medical Hypnosis; Past President,College of Physicians and Surgeons, New York, NY; Developmental ASCH; Past President, SCEH; Past President, International Societyand Behavioral Pediatrician, Morgan Stanley Children’s Hospital of of Hypnosis (ISH); Fellow, ASCH & SCEHNew York Presbyterian Hospital, New York, NY and the BrooklynHospital Center, Brooklyn, NY JUDSON B. REANEY, MD, FAAP, BCB Developmental and Behavioral Pediatrician and Clinical PracticeHOWARD HALL, PHD, PSYD, BCB Director, Park Nicollet Alexander Center, Eden Prairie, MN;Associate Professor, Division of Developmental/Behavioral Physician Lead for Professional Renewal, Park Nicollet HealthPediatrics and Psychology, Department of Pediatrics, Case Western System, Minneapolis, MN; Instructor of Pediatrics, University ofReserve University, Cleveland, OH; Rainbow Babies and Children’s Minnesota, Minneapolis, MN; Board Certified in BiofeedbackHospital Case Medical Center, Cleveland, OH; Board Certified in (BCB); Approved Consultant, ASCHBiofeedback (BCB); Approved Consultant, ASCH LAURENCE I. SUGARMAN, MD, FAAP, ABMH*PAMELA KAISER, PHD, CPNP, CNS* Clinical Associate Professor in Pediatrics, University of RochesterCo-Director, National Pediatric Hypnosis Training Institute; Former School of Medicine and Dentistry, Rochester, NY; DevelopmentalAssociate Clinical Professor, Developmental-Behavioral Pediatrics and Behavioral Pediatrics, Easter Seals Diagnostic and Treatment(DBP), University of California, San Francisco, CA; Former Center, Rochester, NY; President, American Board of MedicalDirector, Anxiety, Stress, and Health Clinic, Children’s Health Hypnosis; Past Vice-President, Fellow, and Approved Consultant,Council, Palo Alto, CA; Clinical Child & Adolescent Psychologist; ASCHApproved Consultant, ASCH THE REV. JAMES W. WARNKE, MA, MSW, LCSWDANIEL P. KOHEN, MD, FAAP, ABMH* Former President, Member of the Board of Directors, and SeniorCo-Director, National Pediatric Hypnosis Training Institute; Faculty Member of the New York Milton H. Erickson Society forDirector, Developmental-Behavioral Pediatrics and Professor, Psychotherapy and Hypnosis, New York, NYDepartments of Pediatrics and Family Medicine and CommunityHealth, University of Minnesota Medical School, Minneapolis,MN; Director of Education and Training, Minnesota Society ofClinical Hypnosis (MSCH); Past President, MSCH; Past President,American Board of Medical Hypnosis; Vice-President (2011-2012),ASCH; Fellow, and Approved Consultant, ASCH; Fellow, SCEH Skill DeveloPMent gRouP FaCilitatoRSDAVID ALTER, PhD, LP, ABPP, ABPH TERESA QUINN, MD, ABMH*Co-Founder, Partners in Healing of Minneapolis; Founder, Institute Assistant Professor, Family Medicine Residency, Park Nicolletfor Brain-Behavior Integration; Private Practice, Minnetonka, MN; Methodist Hospital, St. Louis Park, MN; Diplomate, AmericanPast President, MSCH; Treasurer & Approved Consultant, ASCH Board of Medical HypnosisANDREW J. BARNES, MD, MPH DAVID WARK, PhD, ABPH Assistant Professor, Pediatrics and Adolescent Health, Emeritus Professor of Psychology, University of Minnesota,Developmental-Behavioral Pediatrics, University of Minnesota, Minneapolis, MN; Fellow, ASCH, SCEH; Past President, MSCH;Minneapolis, MN; Former physician member-at-large, MSCH Past President, ASCH; Board Member, International Society of Hypnosis; Approved Consultant, ASCHKEVIN M. HARRINGTON, PhD, LPPrivate Practice, Bloomington, MN; Professional Staff Member, MARK B. WEISBERG, PhD, ABPP, LPChildren’s Hospital and Clinics, Minneapolis, MN; Former Board Clinical Health Psychologist, Diplomate in Health Psychology;Member, MSCH Listed, National Register of Health Service Providers in Psychology; Independent Practice, Minneapolis, MN; Fellow,REBECCA KAJANDER, CPNP, MPH American Psychological Association; Past President, MSCH;Noran Neurological Clinic, Minneapolis, MN Fellow, Past Vice President, Past Secretary, Approved Consultant, ASCHHARRIET KOHEN, MA, MSW, LICSWPresident, MN Society for Clinical Social Work; Partners-in- ELAINE WYNNE, MA, LPHealing of Minneapolis 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
Registration Form* Pediatric Clinical Hypnosis introductory Workshop only September 20-22, 2012 Please type or print clearly. A name badge and statement of attendance are generated from this form.NameAffiliationDepartmentAddress o HOME o OFFICE Mail StopCity State ZipOffice Telephone Number FAXE-mail Receipts, confirmations, and driving directions are now emailed from our office. Please include your email address and print clearly.Degree o MD o DO o PhD o EdD o MSW/ACSW o DDS/DMD o LMFT o MA/MS o RN o CNP o PsyD o OTHERSpecialty o Pediatrics / Subspecialty o Marriage/Family/Therapy / Subspecialty o Family Medicine / Subspecialty o Social Work / Subspecialty o Psychiatry / Subspecialty o Education / Subspecialty o Psychology / Subspecialty o General Surgery / Subspecialty o Nursing / Subspecialty o Podiatry o OT / PT o Dentistry o OtherLicensed in Profession Required License # StateREGISTRATION FEES On or Before August 15, 2012 After August 15, 2012o Registration Fee $ 695 $ 795o MSCH Member $ 610 $ 690o Graduate Student, Intern, Resident, Fellow $ 550 $ 575Graduate Students please indicate your school affiliationo INTRODUCTORY WORKSHOP Please select ONE session you would like to attend Saturday, September 22, 3:05 PM – Hypnosis in Your Work Setting o Primary Care o Anxiety o Pain/Procedural Stress/Distress o Chronic IllnessSpecial Needs Special needs such as dietary restrictions should be indicated in advance; requests cannot always be honored on site.TO REGISTEROnline: Register online with Visa, MasterCard, or American Express at www.cme.umn.edu/intropedshypnosisinfo. In order to protect your credit card information, the Office of Continuing Medical Education (OCME) does not accept credit card payments by phone, fax, mail, in person, or on-site.By Mail: Mail your check (payable to The Regents of the University of Minnesota) with this form to: Pediatric Clinical Hypnosis, Office of Continuing Medical Education, University of Minnesota, University Park Plaza, 2829 University Avenue SE, Suite 601, Minneapolis, MN 55414.If you have any questions, please contact our office at (612) 626-7600, (800) 776-8636, or e-mail us at firstname.lastname@example.org.*The Intermediate and Advanced Workshops require completing a Prior Learning/Needs Assessment. Upon acceptance of your assessment, you will becontacted with registration instructions.