Registration Form

Hold Me Tight Workshop
Registration Form

* Indicates required field

Select Your Workshop Dates/Location *

Your Name *

First

Last

Your Email *

Phone Number *

Partner's Name *

First

Last

Partner's Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Are you seeing a couples counselor? If so, who? *

How long have you and your partner been together? *

What do you hope to get out of attending? *

How did you hear about us? *

If you were referred by another provider, do we have your permission to thank them? *

Yes No

Do you or your partner need parking near the door of the workshop due to physical health issues? This is relevant for the Asheville location. *

Yes No

Regarding CEU or Certificate of Attendance for licensed clinicians, please select: *

Comments *

We understand that this is an educational workshop and is not meant to replace couples or individual therapy. We understand that we are fully and solely responsible for the results and decisions we make regarding the use of the content of this program. We release the facilitators, the program developer and all related institutions from any and all responsibility or promise and accept full responsibility for any change or decision now or ever made regarding our involvement in this program and use of any related materials. *

Agree Disagree

SUBMIT

Hold Me Tight WorkshopRegistration Form

Hold Me Tight Workshop
Registration Form