| Registration Form Secrets of Successful Relationships Tuesdays Oct 27, Nov 3, Nov 10 |
Mail this form with payment to: (make check out to Pam Lipe)
Pam Lipe, M.S., Licensed Psychologist
Relationship Therapy St. Paul
2562 7th Avenue East, Suite 204
North St. Paul, MN 55109
651-414-9793
Pam Lipe, M.S., Licensed Psychologist
Relationship Therapy St. Paul
2562 7th Avenue East, Suite 204
North St. Paul, MN 55109
651-414-9793
Cancellation Policy: Refunds, less a $10 administrative fee, will be given if cancellation notice is
received by October 24. Call 651-414-9793. No refund is offered after October 25. You may
transfer in writing to another person. No partial refund for missed sessions.
received by October 24. Call 651-414-9793. No refund is offered after October 25. You may
transfer in writing to another person. No partial refund for missed sessions.
Sign-up Form
Classes meet from 6:30 to 8:30 PM. Oct 27, Nov 3, & Nov 10, Tuesdays.
Method of Payment:
Send a check with your registration to Pam Lipe,
2562 7th Avenue East, Suite 204, North St. Paul, MN 55105
Couples & individuals of all relational preferences are welcome.
Please return this form with payment to:
Pamela Lipe, MS, LP
2562 7th Avenue East., Ste 204
North St. Paul, MN 55109
Name ______________________________
Partner’s Name______________________
Address_____________________________
City,State,Zip _______________________
Phone ______________________________
Email ______________________________
We will send your workbook by e-mail. May we send you occasional e-mail notices in the future? We
never share these addresses with others. ____Yes,_____No.
Check enclosed payable to: Pamela Lipe
______$125 per couple
______$ 75 per individual
This is a psycho-educational class. It provides attendees with information, and includes
optional discussion activities and homework handouts. It does not provide counseling. You
do not need to share with the large group.
Classes meet from 6:30 to 8:30 PM. Oct 27, Nov 3, & Nov 10, Tuesdays.
Method of Payment:
Send a check with your registration to Pam Lipe,
2562 7th Avenue East, Suite 204, North St. Paul, MN 55105
Couples & individuals of all relational preferences are welcome.
Please return this form with payment to:
Pamela Lipe, MS, LP
2562 7th Avenue East., Ste 204
North St. Paul, MN 55109
Name ______________________________
Partner’s Name______________________
Address_____________________________
City,State,Zip _______________________
Phone ______________________________
Email ______________________________
We will send your workbook by e-mail. May we send you occasional e-mail notices in the future? We
never share these addresses with others. ____Yes,_____No.
Check enclosed payable to: Pamela Lipe
______$125 per couple
______$ 75 per individual
This is a psycho-educational class. It provides attendees with information, and includes
optional discussion activities and homework handouts. It does not provide counseling. You
do not need to share with the large group.