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Psychotherapy Course Registration Form
 Friendly          

Please send one form for each course.

 

Course                                                                                                                                       

                                                                                                                                                   

Semester:   [ ] Fall     [ ] Winter        Site:                                                                                

Name                                                                                                                                         

Address                                                                                                                                     

Occupation                                                                                                                                

Phone (Day)                                                                (Evening)                                             

E-mail                                                                 

Membership Status in MPC   [ ] Member     [ ] Request for Membership

Training Program Status in MPC     [ ] Candidate

You may send your registration forms to either:
PPS Co-Chairs

Suanne Zager, MSW, CSW, BCD                     Jeffrey Glindmeyer, Ed.D.

     Co-Chair, Psychoanalytic Study Program        Co-Chair, Psychoanalytic Study Program

                          518 LaSalle Blvd.                      4031 W. Main St. Ste. 300, P. O. Box 19155

                                       Lansing, MI 48912-4222                            Kalamazoo, MI 49019-0155