Marriage Seminar Registration

First name

Last name

Email

Phone

Please select all that apply to your relationship, whether it was in the past or currently applies.

Communication issues

Escalated fighting (i.e. yelling, breaking items, threats to end the relationship)

Shoving, hitting, kicking, throwing objects at each other, belittling remarks

Infidelity

Addiction (e.g. gambling, alcohol, pornography, drugs)

Chronic illness

Mental diagnosis (e.g. depression, anxiety, ADHD)

Other

Are you and your partner committed to the growth of your relationship?

Yes

No

Other

Any dietary restrictions?

Seminar Fee

Pay in full$200

Reserve my spot (the rest is due at time of the event)$50