Name: ______________________________ Organization: _____________________
Email: ___________________________ Day Phone: __________________________
Evening Phone: ______________________________ I am paying by (check one):
Address: ____________________________________ [ ] Cash [ ] Check
____________________________________ [ ] Money Order
Make checks/money
orders payable to Phoenix Family Institute.
To guarantee registration, please mail registration form and payment to be received by Phoenix Family Institute at least one week prior to specified workshop.
Mail Form and Payment to: Phoenix Family Institute
Charlotte Merchandise Mart
I am a (check one): [ ] Student [ ] Clinician
I will be attending
the following workshop(s) (All are on Wednesdays
from 8 a.m. – 12:30 p.m.):
[ ] Cognitive Behavior Therapy: 11/3/04 [ ] Impact of Depression on Families: 3/2/05
[ ] Family Systems Therapy: 12/1/04 [ ] Ethical Issues in Working with Families: 4/6/05
[ ] Ethical Issues in Clinical Practice: 1/5/05 [ ] Disorders of Early and Late Adolescence: 5/4/05
[ ] Types of Depressive Disorders: 2/2/05 [ ] Depression in Patients with Medical Problems: 6/1/05
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Number of Student Workshops |
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@ $20.00/Workshop |
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Number of Clinician Workshops |
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@ $40.00/Workshop |
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Total Enclosed: |
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Thank you for registering!
Phoenix Family Institute will contact you to confirm receipt.
Questions? Call 704.371.8987, email info@phfamily.com or visit our website at www.phfamily.com.