Replenish Relationships |

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Workshops

Name

Partner Name(Required)

Email(Required)

Partner Email

Phone

Couple Information

Length of Relationship(Required)

How Did You Learn About Our Workshop*(Required)

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)*(Required)

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

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

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

Which workshop date are you interested in attending?(Required)

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Couple Information