Mindfulness and Meditation Retreat for DBT Therapists Registration

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Can we add you to our email list for upcoming trainings and workshops?
- Yes, please.
- No, thank you.
Agency
Affiliation
Food Preferences
Please check the box of any food items that you do NOT eat.
- Red Meat
- Pork
- Poultry
- Sea food
- Shell fish
- Eggs
- Dairy
- Gluten
- Wheat
- Nuts (allergies)
Do you have any food sensitivities/ allergies? If so, what are they?
Lodging Type
Registration fee includes meals, room and board for the duration of the Mindfulness Retreat. In order to prevent the spread of COVID-19, all participants must stay in a private room. Please note that the facilitator, Cedar Koons, MSW, has requested that all participants stay on the premises of the retreat center to minimize possible distractions from the practice.
- Private Room $675.00
Total
$0.00
Promo code
Billing
How would you like to pay for your registration?
- Invoice - Pay by Check
- Pay Now - Pay by Credit Card
Who will be receiving the invoice?
First Last
Invoicing Email Address
Invoicing Phone Number
Credit Card
Please check if you have activated a Stripe feed for your form.
Cancellation notice before November 15th, 2021 required for a refund.*
- I understand
I verify that I have been fully vaccinated for COVID-19.*
- Agree
Questions / Comments
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