Rod Kochtitzky, M.Div - Couples Counseling, Nashville, TN

COUPLES WORKSHOP REGISTRATION

Pay by Credit Card

Please complete form below and submit to Rod. The form will then direct you to the
"PayPal" page to purchase our Couples Workshop via your major credit card.

Your name:
Partner's name:
Address:
City:
State: Zip:
Your E-mail:
Patner's E-mail:
Daytime phone:
Evening phone:
Your Cellular phone:
Partner's Cellular phone:
Special contact instructions:
Are You a Member of WCC
Please select the Workshop of your choice:

Getting the Love You Want: Couples Workshop
$700.00 per couple if registering 2 weeks in advance.
$750.00 if registering 13 days or less before workshop.
Seminars - Please enter amount: $
Date of Workshop you want to attend:
Are you currently in therapy?
If so, which category?
If so, with whom?
(Please discuss attending this workshop with your therapist.)
How did you hear about this Workshop?
Please hit the SUBMIT button, it will then direct you to the next page to purchase via credit card using PayPal. PLEASE NOTE THE AMOUNT YOU ARE PAYING BEFORE HITTING "Submit". (You will need to enter the amount with PayPal).
T H A N K Y O U !