REGISTRATION for "Getting the Love You Want" or "Keeping the Love You Find" Workshop (please circle one)

 

 

Name(s)_______________________________________________

 

Address___________________________________________________________________________________________________

 

Phone numbers_________________________________________

 

e-mail address________________________________________

 

Preparing for marriage? ______   Never married ?____________

Married?___________ Together how long?__________________

Number of children__________________

 

Are you familiar with Dr. Harville Hendrix's Imago Relationship Therapy?___________________________________________

Have you read Getting the Love You Want ?  _____________

Have you read "Keeping the Love You Find"?  ______________

 

 

 Enclosing a deposit of 200NIS for the workshop._______

 

 

Send to:

Charlotte Slopak Goller, Ph.D.

6 Miriam HaHashmonait

93558   Jerusalem

 

Phone: 0544-745369 (NS)

e-mail: charlots@netvision.net.il