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Workshops
parents, Indivdual & couples instruction
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Groups are available by special request. Please call to make arrangements.
Employee groups / Church groups / Law enforcement groups / military groups / caregivers for the elderly /
Prices are based on group size and number of sessions
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Please call to make an appointment and make arrangements for time and location
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Registration Form for Individuals/ parents / Couples
Name:_______________________________________Phone (H)____________(W)____________(C)__________
Address:_____________________________________City_____________________State_______Zip__________
E-mail_______________________________________
__Single __Married __Separated __Divorced __Widowed
Other than your children.....Do you live alone? __Yes __No If No, who lives with you? ____________________
Number of children______Ages / M/F 1.___/___ 2.___ /___3.___/___ 4.___/___5.___/___6.___/___ 7.___/___
Please answer the following questions: (check all that apply)
1. Which of the following best describes you most of the time, when relating to your __children __spouse __other
___ (stressful) ___(frustrated) ___(angry) ___(yelling) ___(power struggles)
2. Which best describes your __child / children / __spouse __other, most of the time when relating to you?
___(stressful) ___(frustrated) ___(angry) ___(yelling) ___(power struggles)
3. Which best describes you most of the time when relating to your child / children's other parent? (if applicable)
___(friendly) ___(hostile) ___(no communication) ___(power struggles)
How did you hear about our services? ____________________________________________________________
My form of payment will be : __check __cash __money order __ sponsorship resource Amount$__________
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