PSYCHO-PHYSICAL THERAPY
WORKSHOP REGISTRATION FORM
Please enter the course and dates you are Registering for:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Name:____________________________________________________________________________
Mailing Address:_________________________________________________________________
_______________________________________________________________________________
Email Address:__________________________________________________________________
Confirmation will be emailed with directions and details 2 weeks prior to workshop dates.
Telephone #:____________________________________________________________________
Fax #:_________________________________________________________________________
Make checks payable to: Bill Bowen. Mail your check and completed registration form to:
Justine K. Polevoy, MFT at 2824 College Avenue, Berkeley, Ca 94705
Payment by credit card: We are able to take Visa and Mastercard payments.
Please contact Justine Polevoy at
510-888-4151 for information about credit card payments.
CEU'S: Bill Bowen Trainings is approved by the California Board of Behavioral Sciences as a
Continuing Education Provider for LCSW's and MFT's in th state of California, PCE #2731.
Cancellation Policy:
Credit towards a future workshop or refund (minus $50) will be provided when notice of cancellation is received by the organizer 30 days prior to the workshop. Credit, but no refund is available if less than 30 days notice is provided. No refunds or credit without prior notification.
Course registration signifies agreement with the terms of the cancellation policy.
For details and other information, please contact:
Justine K. Polevoy, MFT, Phone: 510-888-4151 or
e-mail: EmbodiedPsychotherapy@comcast.net
Return to home page