Getting the Love you Want
Couples Workshop
Therapist Registration

imago couple

Registration is a two step process. Step one is to make payment. Step two is to complete the registration form below.

You can pay the registration fees online through Google. You can also remit a personal check or money order to:

Dr. Tony Victor
6 Emerald Terrace
Suite 4
Swansea, IL 62226

When you have completed payment please return here to complete the Registration Form below.

Thank you. We are looking forward to meeting you.




Getting the Love You Want Couples Workshop
Therapists Registration Form

Please note that all fields followed by an asterisk must be filled in.
A Coffee - Regular
B Coffee - Decafinated
C Tea - Regular
D Tea - Decafinated
E Water
A Coffee - Regular
B Coffee - Decafinated
C Tea - Regular
D Tea - Decafinated
E Water

Please enter the word that you see below.

  

Dr. Tony Victor
618-516-3338