Elly Wynia, LCSW, Individual and Couples Sex Therapist

Couples Workshop - February 2018

PARTNER A

First Name*
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Last Name*
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Zipcode*
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Home Phone
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Dietary Preferences

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PARTNER B

First Name*
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Last Name*
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E-mail*
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Address
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City
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State
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Zipcode
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Home Phone
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Please make sure we have at least ONE phone number for each of you.

Work Phone
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Cell Phone
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Dietary Preferences

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Any Allergies?
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How did you learn about us?
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Whom may we thank for referring you to us?
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Once the deposit is made there are no refunds 60 days prior to the workshop.
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PAYMENT

You may reserve your place with a nonrefundable deposit of $350.
The total price is $700.

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Elly Wynia, LCSW  |  Individual and Couples Therapist * IMAGO Certified * Sex Therapist AASECT certified
53700 Generations Drive Suite 200   |   South Bend, Indiana 46635  |  fax: 574 258 6310   |   phone: 574 258 6300 ext 1   |   Email: imago@ellywynia.com

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