Secure Intake Form: Hold Me Tight - Let Me Go Workshop for Families with Teenagers Questionnaire

Please fill out the following questionnaire if you would like to participate in this workshop. If requested, one of the facilitators can contact you to answer any questions you may have and help determine whether the workshop is a good fit for you and your family.

* = required entry

 


Your Family Information

* Your and your co-parent's name (if applicable):
* Name and age of all children and teens in the family:
* Who will be attending the workshop?
 

Contact Information:

Please provide contact details of where we may reach you and leave confidential messages.

* Home #:
Cell #:
* Email Addresses:
* Full Home Address:


Workshop Information

* How did you find out about this HMT-LMG workshop?
 
* Can you describe some of your goals in attending this workshop?
 
Is there any additional information about your family that could help the facilitator and assistants best support you during the workshop? (e.g., cultural background, recent transitions, losses, etc.)
 
* Are there any worries you have concerning the physical safety of any family members or disturbing feelings you think we should know about?
Yes No
 
If Yes, please describe your concern:
 
* Have you recently been working with a couples therapist?  Yes No
* Have you recently been working with a family therapist?  Yes No
If so, are they supportive of you attending this workshop?      Yes No
In some cases we find it helpful to speak with your therapist. May we have your permission to do so?  
Yes
No
If you consent, please provide your therapist’s name and phone #

Name: Phone #:


Cancellation Policy:

Should you need to cancel your registration for any reason and are no longer able to attend the workshop, we must receive at least 2 weeks' written notice (this can be done via email) and a refund minus a $50.00 administration fee will be issued.

To continue the registration process, please check the box beside the statement below.

* I have read, understand and accept the terms of VCFI's cancellation policy.


Payment Information *

Option 1: $600 CDN (Approximately $460 US per family)
Early bird rate of $500 CDN if paid by June 16th, 2021 (Approximately $380 US)
 
Option 2: For those in need $300 CDN (Approximately $230 US)
 
Payment will be made by PayPal which will convert funds automatically if registering outside of Canada.
 
* Do you want to receive information via email about upcoming Events or Programs? Yes No





 

TOP