Tao of Trauma Demo Day Registration

Name*

Email*

We have been having problems with certain email providers, including Yahoo and AOL. If your primary email is with YAHOO or AOL, please also leave an alternate email below.

Alternate Email

For YAHOO and AOL users

Phone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I am registering as:*

A Clinician: Either as Observer or Bringing a Client
The Client receiving treatment

Name of your referring Clinician?

I am licensed as a:

Please enter "Other" Professional Affiliation here:

For NCBAHM PDAs

Please provide your State Acupuncture license #, NCBAHM #, and date of birth if you would like NCBAHM PDAs

BIPOC, LGBTQ+, or First-Generation Immigrant?

In the spirit of cultural transformation through healing, if you are BIPOC, LGBTQ+, or a first-generation immigrant, please check this box to receive 25% off fees.

BIPOC, LGBTQ+, or first-generation immigrant

I am registering for:

Apr 26th: Observer @ $200
Apr 26th: Clinician bringing Client @ $200

I am registering for:

Apr 26th: Client @ $125

I am registering for:

Fees reflect 25% discount

Apr 26th: Observer @ $150
Apr 26th: Clinician bringing Client @ $150

I am registering for:

Fees reflect 25% discount

Apr 26th: Client @ $93.75

Client Time Preference/Conflict

Client Consultation time slots are at 9:15am, 11am, 1:30pm, or 3pm. If the Client has any preferences or conflicts with the available times, please let us know here so that we may more easily coordinate for the group.

Other/Additional Payment Amount

Enter other payment amount here.

Payment Method*

Checks should be made payable to "Integrative Healing, LLC" and mailed to Integrative Healing, LLC, PO Box 204, Hyattsville, MD 20781. Receipt of your fee will hold your space.

Credit Card
Check

Total

$0.00

Credit Card

Card Details

Cardholder Name

Comments