REGISTRATION

Use this form to request to reserve your seat!

First Name

Last Name

Email

Phone

Group(s) of Interest:

INTO THE FIRE: FIRE WIVES GROUP

MOMS GROUP

WOMENS DIVORCE

MENS DIVORCE

OVERCOMING BURNOUT: MEN

OVERCOMING BURNOUT: WOMEN

TEEN TRANSFORMATION

Are you, or have you been, a patient of Restoration Psychological Services? *

No

Current patient (i.e., individual, couples, or family therapy)

Previous patient

Have attended other groups

By checking this box, I am indicating that I understand that I will be invoiced a $20 registration fee in order to reserve my spot in the requested group if I move forward with registering for the group. REGISTRATION FEE IS CURRENTLY WAIVED FOR TEEN TRANSFORMATION GROUP

Following this request to register, contact will be made by admin or facilitator to gain further information to ensure all participants are a good fit for each group/workshop.

I want to subscribe to receive information about group and other services with Restoration Psychologial Services.

Thank you for your interest!

RESTORATION

PSYCHOLOGICAL SERVICES

PHOENIX

17505 N. 79TH AVE., SUITE 203
GLENDALE, AZ 85308

DrRachelWhite@RestorationPsychServices.com

623-887-3636

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