Please Apply Below

Thank you for your interest in the Relational Joy Group Program. Please fill out the application below and you will be contacted by Dr. Pam.

Name

First Name

Last Name

Spouse's Name

First Name

Last Name

Your Ages

Phone

(###)

###

####

Additional Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Years Married:

Children's Names + Ages

How did you first hear of Dr. Pam and The Relational Joy Program?

Please provide a list of therapists you have seen starting with current therapists and include any from the past. For each, please let us know whether Dr. Pam has permission to contact him or her if need be.

Please check off whether you, your spouse or your children deal with any of the issues below

Anxiety

Depression

Drinking

Substance Abuse

Gambling/Spending

Anger

Physical Health

Workaholism

Sex Addiction

Dr Pam would like each of you to provide a summary giving background information and your wishes for the Relational Joy group coaching program.

Please Apply Below

more info