Workshop Registration Form

1
Which workshop/course are you registering for?
Please Select
Broken Girl, Whole Woman (16+) - Group Sessions
Brother Be Healed (16+) Group Sessions
Broken Girl, Whole Woman (16+) - Individual Sessions
Brother Be Healed (16+) - Individual Sessions
2
Name* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Do you prefer in-person, virtual or telephone meetings?* This field is required.
Please Select
Please Select
In-Person
Virtually (via Zoom)
Telephone
5
Please provide 3 different preferred days and times for sessions.* This field is required.
6
Select Payment Method* This field is required.
Zelle
Cash App
Stripe
Cash (only in person)
7
SignatureI am aware that the total cost of this course is $150.
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