Workshop Registration

New Introduction to Somatic Psychotherapy


Saturday, December 10, 2016

440 Forest Avenue, Portland, Maine

Each day limited to 8 participants

Name and credentials (please print) ________________________________________________
Profession and affiliation _______________________________________________________
Address _____________________________________________________________________
Phone:  work __________________ home ___________________  cell___________________
Email (important – for workshop confirmation)______________________________________

Hours: 6 hours – 9am to 4 pm – meets the continuing education requirements for social worker and mental health counselors in Maine.

Cost of Workshop      $200

TOTAL AMOUNT ENCLOSED:   _____________________
Please print and send the completed registration form
and a check or money order payable to:

Douglas Smith – 9 Cobb’s Bridge Road – New Gloucester, Maine 04260

(Apologies  for the snail mail requirement. We are looking for a plug-in for on-line registration)