Poconos Retreat Registration - Main Line Counseling Partners

PARTNER 1 Name *

First

Last

Email *

Phone *

Please select your lunch option:

Turkey and Havarti on Whole Wheat
Chicken Salad on a Croissant
Vegetarian Pita (Avocado, Portobello, Hummus)

PARTNER 2 Name *

First

Last

Email *

Phone *

Please select your lunch option:

Turkey and Havarti on Whole Wheat
Chicken Salad on a Croissant
Vegetarian Pita (Avocado, Portobello, Hummus)

Please list dietary restrictions, accessibility needs or other circumstances:

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

This retreat is educational and does not take the place of psychotherapeutic assessment and treatment. In the event that you are experiencing fear of your partner, or are concerned about the presence of emotional manipulation or abuse in your relationship, your participation may not be indicated. Click "Yes" below to indicate that understand and agree. *

Yes
No
Not sure, please contact me.

Tickets *

Early Bird Rate - $2,500.00

Spring Sale Ends June 1! 15 Slots Remain

Coupon

Standard: $2500

Total Amount

$0.00

Stripe Credit Card *

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