Healthy Boundaries Workshop Registration

Healthy Boundaries Workshop Registration

Our Healthy Boundaries Workshops are a 3-part series, each of which is held in our conference room (3611 River Road, Ste 200, Yakima, WA 98902). Please have each person who is planning on attending submit a separate form so we can plan accordingly. Thank you!
Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
YesNoI'm not sure
Mondays, March 10, 17 and 24 at 11amFridays, April 11, 18 and 25 at 12:30pmI'd prefer another series, as I can't make the above
Yes, I can make them allI can only make 2 of the 3 sessionsI can only make 1 of the 3 sessionsI'm not sure at this time
By clicking the submit button below, you agree to have the above information sent securely via this HIPAA compliant form to another third-party application managed by Assurance Healthcare & Counseling Center where private data is securely stored. Any identifying PHI (protected health information) will not be transmitted via email or any other insecure format.
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