Riverbend Community Mental Health, Inc. Concord, NH

Your Personal Information
First Name
Middle Name
Last Name
Email
Docket # (Required - this can be found on all your Court documents)
County and Family Division
Co Parent Name (required) (your child(ren)'s other parent)
Mailing Address
Street
Apt#
City
State
Zip Code
Phone number
Seminar Sessions
The seminar consists of two 2-hour sessions. You must attend both sessions Please indicate several choices numbered by preference If the seminars you have selected are unavailable, you will be placed in the next open class	Thursdays March 18th & 25th 6:00 - 8:00 pm Mondays April 5th & 12th 6:00 - 8:00 pm Thursdays April 15th & 22nd 6:00 - 8:00 pm *Please note that your placement in a particular seminar is not guaranteed until it is confirmed by this office
Co-parents will be placed in separate classes unless indicated: Select the option you prefer if you wish to attend the same seminar as your co-parent:	I prefer to attend the same seminar as my co-parent I prefer not to attend the same seminar as my co-parent
Is a restraining order in effect in this case?
Payment and Mailing Information
A $15.00 rescheduling fee will be charged for missed classes. Failure to complete the seminar within six months of your initial registration will require payment in full. Cost per person: $85.00 payment accepted by check, money order, Visa, Mastercard or Discover credit card Registration in seminar will not be confirmed until payment is received.
Option 1: Pay By Check
then mail form and payment to: Riverbend CMHC Attn: Claire Taylor P. O. Box 2032 Concord, NH 03302-2032 Phone : (603) 226-7510 x4321
Option 2: