Please note: To receive skills support services student must complete one of site programs (minimum 8 hours).

See description of various programs available on site vertical toolbar.

Individuals completing Post Traumatic Stress Disorder workbook are excepted.

After completing this form click "submit form". Then please check your emails for confirmation and procedural information.

NOTE: NAME AND ADDRESS YOU GIVE US MUST MATCH NAME AND ADDRESS ON CHARGE CARD BILLING STATEMENT.

* Required fields
Name *
E-mail Address *
The name you give us must match the name on the charge card you are using. Please give us the exact name from that card. *
We will be sending you your workbook or materials by email. Please let us know if you want us to use a different email address from the one listed above. If the same, put "same". *
Street Address or P.O. Box (must match exactly the address on the billing of the charge card you are using) *
City (must match exactly the address on the billing of the charge card you are using) *
State (must match exactly the address on the billing of the charge card you are using) *
Zip Code (must match exactly the address on the billing of the charge card you are using) *
Country *
Telephone number with area code first *
Enter your charge card number (only accepted type of payment) *
Type of charge card (choose Visa, Mastercard, Discover or American Express) *	Visa Mastercard Discover American Express
Expiration Date (mo/yr) *
Enter your charge card verification number. For Visa, Mastercard and Discover, this is the three-digit number on the back of the card after the card number. For American Express, this is the four-digit number on the front of the card above the card number. *
Type of skills support desired (fees are $35 for 1/2 hour and $60 for 1 hour. This is psychoeducational skills support and not a substitute for face to face psychotherapy. It is focused on helping you apply concepts and skills learned in the workbooks. *	Anger Management Family Violence Parenting Animal Abuse Post Traumatic Stress Other
If you checked "other" for type of skills support desired, please indicate type of skills support . Please describe the problems you are having using the information in the workbooks. All information is confidential and will be deleted from the system upon receipt. *
Please indicate best days and time ranges for your skills support appointment. You will be contacted within 2 business days with an assigned time. *

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