Training Institute

REGISTER HERE

Psychotherapy Training Institute Registration Form Instructions: Please print and complete form, and mail with a deposit of $250 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. Call (404) 325-8512 x 721 with any questions.

First Name
Last Name
Address 1
Address 2
City
State
Zip
Home Phone
Office Phone
E-mail
Course	Psychotherapy Training Institute $975
Professional Designation Psychiatrist	Psychologist
	Social Worker
	Licensed Professional Counselor
	Marriage & Family Therapist
	Pastoral Counselor
	Other:
Credit Card (if applicable)	Visa Master Card American Express
Account No.
Expiration
Print Name
My signature below authorizes the charge of $975.00 to the Pine River Psychotherapy Training Institute for the program described above.
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