(Your information is protected and sent through a secure server.)
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.
Please re-type E-Mail:
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.)
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.
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)
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.
How did you find out about the Gottman Relationship Checkup or Dawn Lipthrott, LCSW? (Check all that apply)
Family or friends
Please specify below:
If you have any specific questions or comments, please include them below:
Questions or Comments:
Dawn Lipthrott, LCSW.
c/o The Relationship Learning Ctr.
1177 Louisiana Ave. Ste. 109
Winter Park, FL 32789