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(603) 668-4111

Child Impact Form

Please review before registering:
1.  Co-parents may not attend the same Child Impact Seminar at The Mental Health Center/Bedford Counseling.
2.  Payment must be made at the time of registration. If you are unable to pay the court-ordered fee of $85.00 please contact us at (603) 628-7787 to obtain a fee reduction/waiver application.
3.  You are required to provide your court docket number and court location during registration, and will not receive a certificate of completion after attending the seminar until both are provided.
4. Registration is not complete until we have enrolled you in a class. A notification packet will be sent to you via US Postal Service Mail to confirm your assigned class date and time. You will not be permitted to attend a class for which you do not have a confirmation letter.
 
If paying by checkclick here to print out form, complete and mail it with payment to Bedford Counseling Associates, 1228 Elm Street, Suite 201, Manchester, NH 03101. Classes are also held at this location.
 
Use form below to complete and submit online registration with credit card 

Required fields are marked with an asterisk *.

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Full Name of child's other parent (co-parent):
 
 
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Saturday 8:45 am - 12:45 pm
Two consecutive Mondays 6:30 pm - 8:30 pm
First Available
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401 Cypress Street

Manchester, NH 03103

 

Phone: (603) 668-4111

Fax: (603) 669-1131

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