REGISTRATION FORM
Class Based Upon the New York Times Best Seller “The Seven Principles for Making Marriage Work” by John Gottman, PHD.

Friday, April 13th 6:00 to 9:00
Saturday, April 14th 9:00 to 5:00

Location: The Shepherd’s Staff Counseling Center
200 Park Circle, Suite 1
Flowood, MS

$300 Price includes course materials

Presented by Lida Caraway, M.A., M.S., LPC, Certified Gottman Therapist and Instructor
and assisted by Gregg Caraway

PARTNER #1- Name:
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Partner #1 - Cell Phone:
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Partner #1 - Email Address:
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Partner #2 - Name:
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Partner #2 - Cell Phone:
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Partner #2 - Email Address:
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Please tell us about yourselves. (all information is confidential) How many years have you been married?
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Do you have children?
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If yes, names and ages:
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If married before - Partner #1:
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Divorced or Widowed - Partner #1:
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Children and Ages from relationship - Partner #1:
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If married before - Partner #2:
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Divorced or Widowed - Partner #2:
Your answer
Children and Ages from relationship - Partner #2:
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Please tell us some possible stressors that you have been dealing with lately? job/parenting/health/in-laws....
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Please tell us some things that you hope to gain from this workshop:
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How would you like to pay? PayPal or Mail a check? A deposit of $100 is required to hold your space.
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How did you hear about the workshop?
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