Please enter your information below, print the completed form, and then send it to the address given below, together with your deposit cheque of $50.00 or payment in full, if you wish.
(Your personal information will be kept confidential)
Services Offered:
Rebuilding When A Relationship Ends $480.00 The Next Step $585.00 Couples Counseling $100.00 Per Hour Private One Person Sessions $80.00 Per Hour Resolution $120.00 Per Hour, Review Documentation 80.00 Per Hour
Amount of Cheque:
Name:
Street Address:
City:
Province
Postal Code:
Country:
Phone – Day:
Phone – Evening:
Email:
Today's Date:
For all programs, please mail your completed registration form with a $50.00 deposit cheque to: The SDRC 110 -206 Bearbrook Rd.Ottawa, ON k1b 5r2 Canada
Notes:
Please make your cheque payable to "The SDRC
Once your registration has been received, we will call you to confirm your program start date.
