Gottman Relationship Checkup Registration:

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Be sure to double check the spelling of your and your partner's names AND emails. These will be used to send you the invitation to do the Gottman Relationship Checkup.

YOUR Name


PARTNER's Name
:                    


Mailing Address
:                    


City
:                    


State
:                    


Zip Code
:                    


YOUR E-Mail: 
   


Please re-type E-Mail: 
   


PARTNER'S Email: 
   


Best telephone to reach you: 
   

Gottman Relationship Checkup

The cost to register for the Gottman Checkup is $140, which is my regular counseling session fee. This is to pay for the session to go over the results after you finish the online evaluation and go over possible next steps. I will pay the Gottman Institute for your checkup, so I do not charge an extra fee for that. I will also ask you to fill out standard forms that I use before I meet with a couple. One is basic information. The other asks you some other questions about goals you already have, what you see as the main thing needing improvement, etc.

(The fee includes the checkup online, and the meeting with me to go over the results.)

Cancellation:
If you choose to cancel your session with me, I cannot mail you the results. The Gottman Institute insists that it be done in person with a therapist. If you choose not to come in, you will be billed a $50 fee for the checkup itself. Certainly, if you need to change your appointment time, just let me know.

Payment Information (Visa, MasterCard or Amex)

You may enter your payment details here through our secure server for full fee or deposit.

Credit Card Number:


3 digit code on back or 4 digit code on front of Amex
:



Expiration date: (XX / XXXX)
                    


Cardholder Name:
                  


Zip Code for credit card billing address:
                    

By filling out my credit card information, I hereby authorize billing in the amount of $140. I understand that if I change my mind and decide not to do the checkup once I or my partner have started it, or choose to not meet with Dawn Lipthrott, LCSW to go over the results, my card will be billed $50 to cover the cost of the checkup itself.

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Contact Info

Dawn Lipthrott, LCSW.
c/o The Relationship Learning Ctr.
1177 Louisiana Ave. Ste. 109
Winter Park, FL 32789

Telephone: 407.740.7763