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Training Institute

REGISTRATION
FORM


Call (404) 325-8512
with any questions.

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Submit via e-mail to prpti@bellsouth.net or Please print and mail/fax to: 1145 Sheridan Road, NE Atlanta, GA 30324 Fax: (404)325-8733

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

CEU CATEGORY

Psychologist, 6 CE credits offered
LPC/MFT/Social Work:  6 Core Hours offered.

Checking this box indicates your undersanding that an additional $25 processing fee (check payable to PRPTI) will be due at check-in on the day of the workshop.

Workshop

LET'S TALK ABOUT SEX
$180 by 3/3/16. No on-site registration is available.
Cancellation Policy Cancellations before February 20th are refundable less a $30 administrative fee per registrant. No refunds are available after February 20th.

If your plans change on or after 2/21/2016, please contact us as we will gladly apply your entire registration fee to an upcoming PRPTI workshop
Credit Card
(if applicable)
Visa Master Card American Express
Account No.
Expiration
Print Name

Space

limited to 40 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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