Workshop Policies, Workshop Agreement & Conflicts of Interest Disclosure

Crucible^® Clinical Practicum

Crucible^® Clinical Practicum
Workshop Policies

Clinicians attend this workshop primarily to increase their effectiveness as therapists providing direct service to clients in some form of mental health office practice. Secondarily, clinicians may gain some personal benefit for themselves and their relationships. This is not a workshop on training other therapists, nor is it training as a workshop leader. The information, activities and handouts provided are for your benefit in working with clients, rather than for supplying material for your own workshops or publishing activities. We would not like to find workshop participants using the fruits of our labor in inappropriate ways in their publications, media and/or workshops for professionals or the public. We hope you will respect the time and effort we have spent developing this material.



Our workshop materials and other publications are copyrighted and not for duplication or distribution. Moreover, besides no copying, plagiarizing, duplicating or distributing our copyrighted materials, you should be heedful that “derivative work” includes, but is not limited to, adapting, rewording or modifying our material or presentations for your own purposes. All lectures are recorded and copyrighted (although not always distributed); the notes you take during the workshop are a derivative work. We consider using your notes to guide you in direct service to clients in office practice to differ from distributing them to other clinicians or non-clinicians. Here again, beyond the legal issued involved, we ask that you observe the more important and stringent criteria of professional ethics, personal integrity, and collegial good will in how you use what you learn in our workshops.

Attending this workshop does not sanction you to represent yourself as a practitioner or representative of the Crucible® Approach, nor does it grant you permission to advertise our trademarks. Training in the Crucible Approach can only be provided by the Marriage u0026amp; Family Health Center. Practices that violate trademarks and/or collegial fairness include – but are not limited to –advertising or conducting workshops that appear to be training in our trademarked approaches, as well as using names and labels for your publications and programs that confuse the public or other therapists, or that blur the distinction between our work and yours. In representing your attendance at this workshop in your advertising or citing your professional credentials, you agree to provide specific information regarding its nature and duration, rather than through vague statements such as “trained in the Crucible Approach” or “studied with David Schnarch.”

Workshop Agreement

By my signature below I acknowledge reading and agreeing to the foregoing “Workshop Policies” and specifically agree to the following:

I am disclosing potential conflicts of interest (if any) on the form provided.

I agree not to use or infringe upon trademarks owned or pending by the Crucible Institute or David Schnarch, Ph.D., which include (but are not limited to) “Crucible”, “Sexual Crucible,” “CrucibleApproach,” Passionate Marriage” Passionate Couples,” “Four Points of Balance,” I will make no use of these marks without prior written permission.

I recognize the Crucible Institute and David Schnarch, Ph.D., as owners of copyright rights in and to the workshop lectures and materials, including but not limited to the course handbook, slides, and training materials. I agree not to reproduce or distribute these materials in any form or part or derivative works, or by any means, electronic or mechanical, including but not limited to photocopy, recording, or any information storage and retrieval system, without prior written permission.

I agree to make no commercial use of materials, lectures, or other proprietary information disclosed during this workshop beyond their application in direct service mental health practice with individuals, couples, or families, or in group therapy without prior written permission.

If I do not wish to abide by the “Workshop Policies,” or decline to complete the “Conflict of Interest Disclosure” or sign this “Workshop Agreement,” my registration fees will be refunded. I understand the Marriage u0026amp; Family Health Center reserves the right to refuse participation in the workshop to those who do not complete and return these materials.

I agree to participate in the Crucible^®Clinical Practicum Workshop under the above guidelines:

Signature of Workshop Registrant: _______________

Printed Name: _ Date:_

Professional discipline you are currently licensed to practice: ____

State of licensure: _   License number:

(Or academic institution you are a registered graduate student in a mental health discipline:

   Area of study:

Professional degrees you hold (Degree, area of study, year of degree, school.):

_________________

OR I decline to participate in the Crucible^®Clinical Practicum Workshop:

Signature of Workshop Registrant: _

Printed Name: _ Date:



Conflicts of Interest Disclosure

We don’t want our interactions with you during this workshop to be based on one set of premises, while other agendas are operating underneath. Therefore, we are raising important issues mental health professionals often ignore. When not dealt with thoroughly and openly in advance, they tend to be handled poorly if and when they surface later. Below we ask you to disclose any potential conflicts of interest you may have with us, or any you might reasonably anticipate. These include (but are not limited to) workshops, trainings, business applications, publications, and other materials you are preparing or planning to develop or conduct that may overlap with our work in general, and specifically, the topics and content of this workshop. Also include pending or foreseeable legal actions in which you are involved, which might include us or arise from your participation in this workshop. If you are a practitioner or a trainer of a trademarked therapy or educational approach, please identify yourself as such.

POTENTIAL CONFLICTS OF INTEREST:

________

_ (Attach other sheet if needed).

BE SURE TO CHECK HERE IF YOU ARE REPORTING NO CONFLICTS OF INTEREST

Signature: _Date: _

Print name:______________________________________________________

PLEASE COMPLETE, SIGN u0026amp; FAX THESE FORMS TO 303-670-2392. YOUR REGISTRATION IS NOT CONFIRMED UNTIL YOU RECEIVE NOTIFCATION WE HAVE RECEIVED AND APPROVED THESE FORMS.