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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.
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, 2 Wall Street, Suite 300 Manchester, NH 03101. 
 
*Classes are held at 2 Wall St., Manchester and 121 Railroad St., Keene 
 
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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Manchester - Saturday 8:45 am - 12:45 pm
Manchester - Two consecutive Mondays 6:30 pm - 8:30 pm
Manchester - First Available
Keene - Saturday 9:00 am - 1:00 pm
Keene - Two consecutive Tuesdays 6:00 pm - 8:00 pm
Keene - First Available
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401 Cypress Street

Manchester, NH 03103

 

Phone: (603) 668-4111

Fax: (603) 669-1131

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