Workshop Name* Workshop Name*Getting The Love You WantGetting Even More LoveCorporate Compassion

First Name*

Last Name*

Partner First Name*

Partner Last Name*

Your Email*

Partner Email*

Your Full Mailing Address so we can get manuals to you*

Contact Phone*

Length of Relationship*

How Did You Learn About Our Workshop*

How Did You Learn About IMAGO Therapy? (generally)*

Any concerns we should know about related to the workshop (i.e. Mental Health concerns -only if this is relevant to the work in a group setting)*

History of Violence in the relationship (This is a screening question)*

How would you like your receipt: either communication consulting, individual relationship counselling in either/both names, or couples' counselling

Anything else that you would like us to know about your reasons for attending?

Which workshop date are you interested in attending?