Sign Up for Dr. Rita's UpdatesRegistration Form & Information Request

Registration Form & Information Request
Please fill out the following information and we will get in touch with you shortly.
All information provided is kept confidential. Fields in RED are required.

Name of Class or Program:
   
Email Address:
Name:
Age:    
Partner's Name:
Age:    
Relationship Status:
Length of Relationship
(for couples programs only)

Where did you learn of The Relationship Center?
Is it OK for us to leave a message at the number(s) you provide?
Street Address:
City, State, Zip:
Preferred Telephone:
Alternate Telephone:
   
Preferred Location: Blue Bell
Philadelphia
Online
     
Would you like to receive Dr. Rita's Updates by email?
After you click SUBMIT below, your registration will be sent to Dr. DeMaria. To finalize your submission, please mail your check to The Relationship Center, 790 Penllyn Blue Bell Pike, Ste 104, Blue Bell, PA 19422.