Registration Form

Name: *

Address: *

City: *

State: *

Zipcode: *

Home Phone:

Cell Phone: *

Email: *

February 25-27, 2022

$250.00 paid by February 1, 2022 $275.00 Full tuition paid by by February 25, 2022

Couples:$425.00 paid by February 1, 2022 Couples:$475.00 paid by February 25, 2022

Please send your check to:
Phoenix Center for Healing, P.A.
14875 SW 238th St.
Homestead, FL 33032

Please answer the following questions:

Are you currently under the care of a mental health professional, i.e. Psychiatrist, Psychologist, Counselor, Therapist, etc.?

If so, are you currently taking medication for your mental health condition, i.e. anti-depressants, anti-anxiety, etc.

If so, please contact Aida and or Bob, to discuss the extent of your participation in the weekend.

I am eager to begin this next step in my growth, and I am committing to myself and to others in the group to complete this weekend.