Relationship Conversation with Dr. Elaine Stevens
Class Registration Consent Form
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1.
First and Last Name
(Required.)
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2.
Phone Number
(Required.)
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3.
Email A
ddress
(Required.)
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4.
Course you are registering for
(Required.)
Picking up the Shattered Pieces of a Broken Heart
Healing from the effects of Psychological Abuse
Sibling Relationships
5 Rules for Dating during a Pandemic
The Spirit of the Unchosen
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5.
How did you hear about this course?
(Required.)
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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.
(Required.)
Agree
Disagree
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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.
(Required.)
Agree
Disagree
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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.
(Required.)
Agree
Disagree
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9.
Signature
(Required.)
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