First Name*

Last Name*

Your Preferred Name for Table Tent*

Email Address*

Phone Number*

Billing Street Address*

Billing City

Billing State

Billing Postal Code

Are You A Licensed Practitioner? (Select Your Licensure Below)

License #

Partner's First Name

Partner's Last Name

Your Partner's Preferred Name for Table Tent

Partner's Email Address

Partner's Phone Number

Is Your Partner a Licensed Practitioner? (Select Your Licensure Below)

Partner's License #

If you need to cancel your registration you will receive a full refund, minus a $50 processing fee, provided your request is received prior to 3 weeks before the workshop. If your cancelation is received within 3 weeks before the workshop, you will receive a full credit to attend a future St. Louis Couples Workshop if scheduled within the next year.

This couples workshop is psycho-educational. It is not meant to be therapy. If you would like a referral to therapy we will be happy to help you. 

If you and your partner or spouse are seeing a therapist you may wish to schedule a session soon after the workshop for extra support. Are any of the following conditions present in your relationship?

Legal mandate to complete an anger management or domestic violence program.

A conviction of assault or domestic violence.

Unwanted physical aggression in your relationship.

Issues, conditions or concerns that might affect your participation in the workshop.

If any of these conditions exist, Richard or Christianne will discuss them with you during your phone call. 

Closer to the workshop, each member of each couple has their own   phone call with Richard or Christianne to answer any questions about the workshop, to hear what attracted you to the workshop and help us ensure that the workshop may be useful for you and your partner.

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