Return Registration to:

CompassionWorks
1709 Savage Drive
Plano, TX  75023
Phone (214) 668 2727    Fax:  (972) 527 9563

Name: ________________________________________
            (As you would like it to appear on your certificate of completion)

Professional Title: ________________________________

Professional Lic. # ________________________________

Lic Exp. Date ____________________________________

Mailing Address __________________________________

City ____________________ State ______ Zip _________

Contact Phone ___________________________________

Please include full payment with registration.  $1450 ($1350 if reg. before 9/3/08.  Additional $100.00 discount for therapists
working in the non-profit settings, interns, and post-graduate
students.

Method of Payment

_____  Check for $__________
                                Payable to CompassionWorks

_____  Charge the amount of $ ____________ to my

Visa, MasterCard or Discover (Circle one)

Card #_________________________________

Exp Date ______________

Name on card ___________________________________

Address card billed to _____________________________

___________________________ Zip ________________

Signature _______________________________________