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Traumatic
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traumatic incident reduction

TRAUMATIC INCIDENT REDUCTION

TIR ENQUIRY FORM

You may use this Enquiry Form to:

Please fill out as much information in the fields below as possible. All information will be held in confidence and your name will not be used for any purpose other than our responding to you in the manner that you request. This form can be submitted to us automatically from your web browser by clicking on the Submit button at the end of the form.

For questions, suggestions or comments regarding the mechanics of this Website itself or technical problems with this form, rather than the content therein, please contact the Healing Center Webmaster.

 


NOTE: THE INTERACTIVE SUBMIT FEATURE
OF THIS FORM IS   NOW   OPERATIONAL!


First Name:
Last Name:
Title:
Other:
Degree:
Other:
Organization:
(if applicable)
Street:
City:
State or Province:
Other:
Zip or Postal Code:
Country:
E-Mail Address:
Telephone:
FAX:

Occupation:
Other:
Professional Affiliation:
(if applicable)
How you found us:
Other:
In which sector do you
operate?:

Other:
In what areas are you
interested?:

Other:
What services/materials
would you like to
know more about?:

Other:

Are you currently using TIR
in your practice as a therapist,
counselor or helper?:
Yes   No
Would you like to use TIR
in your work as a therapist,
counselor or helper??:
Yes   No   Not Sure
Would you like to enroll
in a TIR training workshop?:
Yes   No
What current location is
most convenient for you to
attend a workshop?:
What current dates are most
convenient for you to
attend a workshop?:
Are you interested in
finding a TIR facilitator
in a certain area?:
Yes   No
If so, in which
US State or country?:

Other:
Would you like a TIR
facilitator
to contact you?:
Yes   No
Are you interested in
conducting or participating
in clinical research on TIR?:
Yes   No
Would you like to be
added to our mailing list?:
Yes   No
Would you like to be
notified when our
website is updated?:
Yes   No
Would you like to become
a TIRA Member?:
Yes   No  Already a Member

Do you have any additional comments or questions?:






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