Healing the Heart (July 13th-20th, 2025)

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Name

*

Email

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This address will receive a confirmation email

Phone

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Address

*

Marital Status

*

Please select one option.

Single Married Seperated Divorced Widowed

Are you at least 18 years old?

*

Please select one option.

Yes No

Do you attend church, if yes, which one?

*

Are you currently in counseling?

*

Please select one option.

Yes No

Do you have any dietary allergy/restrictions? If so, please explain.

*

Do you have any special needs? If so, please explain.

*

Are you able and willing to commit to be at all the sessions?

*

Please select one option.

Yes No

If filling out this form, or paying for another person, please list your name here.

Payment

Payment in Full ($175.00) Deposit ($100) Remainder After Deposit ($75) Other payment arrangements (Your spot is not secure until deposit is made) ($ 0)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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