Register for the Couples Workshop

We look forward to seeing you at an upcoming couples workshop!

33%

Workshop*
To register, please fill out all the steps of the form. If you have any trouble with the form or Paypal, please contact us.
IMPORTANT:

Please note: registration is not made until all the steps are complete.

Your Details

Fill in your details
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City ZIP Code
Partner Name*
First Last
Does Your Partner Have The Same Phone Number as You?*
- Yes
- No
Partner Phone*
Partner Email*
Does Your Partner Have The Same Mailing Address as You?*
- Yes
- No
Partner Address*
Street Address Address Line 2 City ZIP Code
IMPORTANT:

Please note: registration is not made until all the steps are complete.

I have read and agree to the Refundability Agreement:*
- Yes
(Click Here to Read Refundability Agreement)
Newsletter
- Yes, I want to sign up for the newsletter
Please Choose to Pay Either the Full Registration Fee, or Deposit.*
Total
$0.00
Please choose a payment option:*
- Pay by Check - Greatly Preferred
- Pay with Credit Card Using Paypal
If your desire is to pay by check, simply mail your check asap (must be postmarked within 24 hours of your Registration.).

Payable to:
Damian Duplechain LPC, Inc.
5959 West Loop 610 South, Suite 600, Bellaire, TX 77401.

Make it in order to continue to hold your Workshop slot.
NOTE: Total fee balance is due no later than 14 days before the Workshop, i.e., before 6:30 pm on the 2nd Friday before your Workshop weekend.

NOTE: Registration confirmation will be emailed within 24 business hours, containing venue directions, instructions, suggestions, and hotel discount information. Note also that it's not required to spend the night at the hotel, only a recommendation. Upon receipt of your registration confirmation, please immediately reply to confirm you have indeed received it.
How did you learn about us?*
Other (Please specify)
Whom may we thank for their recommendation of the Imago Couples Workshop to you?