Creve Coeur Counseling Institute

Registration

Name ____________________________________________________________

Address __________________________________________________________

_________________________________________________________________

City, State, Zip _____________________________________________________

Phone _____________________ Alt Phone ______________________________

E-mail __________________________________

Seminar Choice(s):

__ NOVEMBER 14, 2009: Addictions Part II: Other Addictions

__ DECEMBER 12, 2009: Working With Veterans

__ JANUARY 9, 2010: Men’s Issues

__ FEBRUARY 13, 2010: Working With Families

__ MARCH 13, 2010: Wholistic Counseling

Fees:

Individual Seminar: $25
Series of Three: $65 (save $10)
Full Series of Six: $125(save $25)

*Additional $5 discount for Groups of 4 or more registered and paid at same time


Payment Method:

___ Check enclosed. Make out to Nancy Golden.

___Credit Card Payment (Visa or Master card)

Card #______________________________

Exp. date __________

Name on card ________________________

Signature ___________________________

Please mail your registration form to:

Nancy Golden
Creve Coeur Counseling Associates
939 Gardenview Office Parkway
Creve Coeur, MO 63141

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