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Training Institute

REGISTRATION
FORM


Call (404) 325-8512
with any questions.

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First Name
Last Name
Address 1
Address 2
City
State
Zip
Home Phone
Office Phone
E-mail

CEU CATEGORY

Psychologist
LPCA
LCSW
MFT

3 CE credits available
3 hours of Continuing Education are being applied for via Alliant International University. These hours are categorized under Area IV in the state of Georgia for psychologists. Alliant International University is approved by the American Psychological Association to sponsor continuing education for psychologists.

Workshop

I'm OK if We're OK with Avrum G. Weiss, Ph.D.
$140, by March 29, 2019
Credit Card
(if applicable)
Visa Master Card American Express
Account No.
Expiration
Print Name

Space

limited to 15 participants
My signature below authorizes the above charge to the Pine River Psychotherapy Training Institute for the program(s) described above.
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E-Mail: prpti@bellsouth.net, or Fax: 404-325-8733

or call 404-325-8512 to register

 

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