Couples Weekend Retreat Enrollment Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in our Couple's Therapy Workshop and Retreat. Please fill out the form below and a member from our team will get with you to schedule a consultation.

Your Name *

Your Partner's Name *

Email Address *

Phone Number *

Address *

Reason for attending a Couple's Retreat

What are you hoping to get out of the couple's workshop?

Are you and your partner willing to commit to both days of the workshop?

Yes

Need more information

Clear selection

Have you and your partner attended couple's therapy in the past?

Yes

Clear selection

Location

Broward

Palm Beach

Tampa

Online

Clear selection

Requested Clinician

Altagracia Andre (Wellington) https://caringtherapistsofbroward.com/staff/altagracia-andre-lmft-therapist/

Connie Francis (Palm Beach Gardens) https://caringtherapistsofbroward.com/staff/connie-francis/

Jersey Garcia (Tampa & online) https://caringtherapistsofbroward.com/staff/jersey-garcia/

Rosemary Scheppske (Davie) https://caringtherapistsofbroward.com/staff/rosemary-scheppske-lmhc-therapist/

First available/No preference

Clear selection

Are you aware that this workshop is private pay only and there will not be reimbursement from your insurance company?

Yes

Clear selection

How did you hear about us?

Google

Referral from a friend/family member

Podcast

Blogpost

Other:

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Caring Therapists of Broward. Report Abuse

Forms