Register Your Interest

I am /we are interested in participating in this workshop in 2017:

Workshop title*
Workshop location*
No. of people interested in attending workshop*
Goal/s for attending the workshop
Background /profession of participant/s
Preferred dates/ months to attend
Any specific dates/ months cannot attend
Full Name*
Email address*
Mobile / phone no.
Can a message be left on your phone by the psychologist?
Additional comment