REGISTRATION FORM

Name: ..................................................................... Surname: .................................................................

Profession: • Psychoanalyst • Psychoanalytic Candidate • Psychologist • Psychiatrist • Psychological Counselor • Social Service Specialist • Psychiatric Nurse • Student/Assistant
Degree of education and/or academic title: .............................................................................................. ...................................................................................................................................................................

Place of occupation and/or institution of training....................................................................... ...................................................................................................................................................................

Address: ....................................................................................................................................................... ...................................................................................................................................................................

Postcode: .............................................. City: ......................................................................................

Telephone: ................................................................ e-mail: .....................................@..............................