Training Institute

Getting The Sex You Want

Dr. Tammy Nelson

REGISTRATION
FORM

Call (404) 325-8512 x 721 with any questions.

Back to Workshop Descriptions

Please print and complete form, and mail to: Pine River Psychotherapy Training Institute, 1145 Sheridan Road, NE, Atlanta, GA 30324. If paying by credit card, please fax the application to (404) 325-8733.

First Name
Last Name
Address 1
Address 2
City
State
Zip
Home Phone
Office Phone
E-mail
	$ 20	Friday Night Lecture
	$ 90	Saturday Seminar (6 CEUs)
	$ 100	Both
CEU CATEGORY	Psychologist (Area III)
	LPCA
	LCSW
	MFT
	6 core CEU's available through LPCA, GAMFT, NASW and GPA Area III
Credit Card (if applicable)	Visa Master Card American Express
Account No.
Expiration
Print Name
Space	limited to 30 participants
Cancellation Fee	$25 administrative fee for cancellations less than 8 days
My signature below authorizes the above charge to the Pine River Psychotherapy Training Institute for the program(s) described above.
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