Class Registration Consent Form

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* 1. First and Last Name

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* 2. Phone Number

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* 3. Email Address

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* 4. Course you are registering for

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* 5. How did you hear about this course?

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* 6. I personally give Dr. Elaine Stevens permission to consult with me concerning my relationship issues within the group or outside of the group. I understand that Dr. Elaine Stevens will not be responsible for any adverse behavior or choices I make as a result of these sessions.

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* 7. If there is a charge for the class, I agree to pay all charges in full before the class begins. 

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* 8. I will only speak about issues from class that pertain to me only. I will not discuss any class information with anyone outside of the group.

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* 9. Signature

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