Registration – Life Sculpting, LLC

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LivePod
Testimonials
Registration
About Me
Services
LivePod Group

Discussion Registration

First Name *

Last Name

Date of Birth *

Email Address *

Telephone

Street Address *

Apartment, suite, etc

City

State

ZIP Code

Do you have insurance? *YesNo

Plan Name *

Member ID *

Group Number *

Consent *

Yes, I agree with the privacy policy.

Signature *

Date *

Dyan Auterson is licensed in the state of Georgia. Anyone registering for the Live Discussions who lives out of state will not be able to use their health insurance policy. Under these circumstances, a registered participant will need to pay the one time fee for the discussion.

Total

Dyan Auterson
LPC., CCTP-II., NCC., MA.
Phone: (404) 630-7051
Fax: (404) 393-3949
Dyan@LifeSculpting.org

Licensed Professional Counseling | National Certified Counselor | Level II Certified Clinical Trauma Professional