First Name *

Last Name *

Preferred name for your table tent *

Email address *

Phone *

Address *

City *

State *

Postal code *

Are you a Licensed Practitioner? (Select your licensure below) *

License #

Partner's Information

Partner's First Name *

Partner's Last Name *

Partner's preferred name for table tent *

Partner's email address *

Partner's Phone Number *

Is your partner a Licensed Practitioner *

Partner's License #

Cancellation

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.

I have read and agree to the workshops cancellation process. *

Psycho-Educational Program

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.

I have read the Psycho-Educational statement and understand that The Art and Science of Love Workshop is not therapy. *

Pre-Workshop Considerations

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.

I have reviewed and agree to the Pre-workshop Considerations. *

Pre-Workshop 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.

I have read and agree to participate in the Pre Workshop Phone Call. *

How did you hear about us?

Do you have any other comments or special needs?