Pivotal Response Treatment (PRT) Training and Certification Koegel Autism PRT
Registration Form One registration form per person per level of certification please.
$300: Level I Certification: Introduction to PRT $450: Level II Certification: Introductory Implementer $500: Level III: Certification Generalization
$600: Level IV: Advanced Implementer of PRT for Initiations $600: Level IV: Advanced Implementer of PRT for Self-Management $600: Level IV: Advanced Implementer of PRT for Socialization
Level V Certification: Trainer of Trainers
Name Degree (Last, First)
Phone Number
Address
City
State/Zip
Date of Registration:
Check Enclosed to Koegel Autism Consultants Credit Card Online Transaction ID:
Please continue to Page 2 Experience Experience in the Field of Autism
1 Related Pivotal Response Treatment Experience
PRT Trainings/Dates Completed
Levels of PRT Certification Completed
Experience Implementing other ASD Intervention Methodologies (e.g. DTT, Floor Time, Sensory Integration, PECS, etc.) Please describe below.
Please send registration with check in sealed envelope to: Koegel Autism PRT Certification Attn: Kristin Wheatley 1547 Palos Verdes Mall #416 Walnut Creek, CA. 94597
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