Registration — Three Pillars Workshop Registration Form - Attachment, the Body & Relational Repair: Three Pillars Workshop, Fall 2025 with Lisa Mortimore, PhD Name(Required) First Last Business Address(Required) Street Address Address Line 2 City Province Postal Code Business Phone(Required)Business Email(Required) Educational Degree and Discipline(Required)Are you registered with a professional body?(Required) Yes No Professional BodyRegistration NumberPlease include a copy/picture of your graduate degree if you are not a member of a professional associationMax. file size: 128 MB. How did you hear about this training?Referral from a colleagueReferral from a past participantGoogle searchSocial media (Facebook, Instagram, LinkedIn, etc.)EmailNewsletter or blogPodcast or interviewConference or workshopProfessional association (BCACC, CCPA, etc.)OtherPlease specify: Program Description and Expectations The Savoy Clinic Ltd. (The Savoy Clinic) seeks to deliver training and professional development opportunities of the highest calibre. Our goal is to create a culture of inclusion, safety, and the pursuit of excellence in all aspects of the workshop and learning experience. As a Participant, you play an integral role in creating this environment, and need to uphold the above values with us. This workshop provides an opportunity for therapist development and evolution. Participants must, at all times, practice in accordance with their own professional scope and within the code of ethics of their own professional regulatory body or association(s). If you do not belong to a professional regulatory body or association, you are expected to follow the BC Association of Clinical Counsellors’ (BCACC) Code of Ethical Conduct, as may be amended from time to time. Participation is restricted to practicing therapists with an active caseload and a graduate degree in a clinical mental health discipline. It is likely that during the workshop some of your own unprocessed material may emerge. Participants are responsible for making arrangements to engage in their own personal support as needed during the workshop including, but not limited to consultation, supervision, and personal therapy. The Personal Information and Protection Act (PIPA) applies to the psychotherapeutic and educational activities of The Savoy Clinic. As a Participant you must respect and safeguard the reasonable expectation of privacy and confidentiality of your fellow Participants, as well as all client information presented or discussed during the training program. Your enrollment is contingent on your agreement to protect all communicated and stored client and Participant personal information and to comply with applicable legislation, ethical guidelines and regulatory standards related to privacy and confidentiality at all times. Virtual participation in the training program must occur in a private environment which is protected from intrusion by, or exposure to, unauthorised persons. In other words, Participants must ensure that others in their household or office setting cannot overhear any aspect of the training, including the Participant’s participation, or overlook their computer screen. Participants must close all social network apps during virtual or in-person training sessions, and must ensure that any voice activated devices, including their cell phone, are not inadvertently recording or transmitting. The content of all educational materials provided to you as a Participant is the intellectual property of The Savoy Clinic, and must not be shared, posted, copied, emailed, transmitted, or used outside of the workshop except as a reference used only by the Participant to inform their clinical practice. Participants are NOT permitted to record any or all parts of the workshop. Participants are NOT permitted to use AI notetaking programs. The workshop is conducted entirely online. Participants must have a stable internet connection, a computer/laptop with a camera, and a private workspace. Phones, iPads, or tablets are not sufficient for full participation. Training is delivered via Zoom for Healthcare. Participants should ensure their internet meets Zoom’s system requirements: Zoom System Requirements. Registration and Information For any questions regarding registration, please contact: Email: trainings@lisamortimore.com Phone: 250-514-4731 Program Fees Earlybird Workshop Fee: $595 including GST before October 15th, $635 thereafter Workshop Dates: Wednesday Evenings, October 29 to November 26, 2025, 6 - 9 pm PT Next Steps After Submitting This Form To complete your registration, please follow these next steps: Send your non-refundable deposit of $300.00: Please e-transfer the payment to trainings@lisamortimore.com to secure your spot. If you have any questions, please contact The Savoy Clinic at: Email: trainings@lisamortimore.com Phone: 250-514-4731 Fee Agreement(Required) I confirm have read and agree to the below Fee Agreement.Registration for the workshop requires payment of a non-refundable deposit of $300.00 in order to secure your space. The remainder of the workshop fee is due one week prior to the first class. If you need a payment plan, please reach out to make arrangements. BBP Code of Conduct(Required) I confirm have also read and agree to abide by terms of registration and agree to the indemnity clause below.Under no circumstances will The Savoy Clinic, or its directors, officers, or employees be liable to you or to any other individual for any loss, claim, injury, or damage, whether foreseeable or unforeseeable, arising from your participation in this workshop including, but not limited to, your application of the concepts taught by The Savoy Clinic.Signature(Required)Date(Required) MM slash DD slash YYYY
