Please print this form and mail it with your check to:

Gestalt Center for Psychotherapy and Training

220 Fifth Avenue, Suite 802

New York, NY 10001

Make check payable to: The Gestalt Center

Today's Date: Degree

How did you hear about us?

Name (please print):

Address:

City State Zip

Home Phone: Other Phone:

E-Mail Address: ______________________________________________

Discounts:

You may take one of the following discounts, if applicable.

(Discounts may not be combined.)

Graduate students in the mental health field receive a 30% discount.

Students enrolled in the Gestalt Center receive a 50% discount.

Gestalt Center alumni (who have paid alumni dues) receive a 30% discount.

Please register me for:

Workshop Date Fee

Amount Enclosed:

Registration for all workshops must be received at least 1 week in advance.

Cancellation Policy: Partial refund for cancellations received more than 7 days before your workshop.