Please fill out the below form and I will get back to you shortly. Date* MM slash DD slash YYYY Name* First Last Phone*Email* Cancellations received at least 10 days before the workshop are refundable less a $25 administrative charge per registrant. There is no refund for cancellations received later. Please note that if you register and do not attend, you are still liable for full payment. If the organizers for any reason cancel the workshop, a refund or voucher will be issued to any participant who is registered to attend the workshop.Session* Clinical Consultation - $150.00 Clinical Supervision - $100.00 Total $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name
