Questionnaire

 

Thank you for submitting the form below. Please complete the * sections to provide the confidential information needed to complete your registration. The rest of the questionnaire is optional, however, your willingness to complete it will help us know you better as you embark on this journey. If you are registering as a couple, please have each person complete a questionnaire. Your participation in the workshop/group will be confirmed upon the receipt of your payment along with the submission of Questionnaire and Informed Consent Form found under the "FORMS" tab. If filled out here, this form will be electronically submitted. Or it can be printed off and mailed to me: Dianne Morris Jones, 7137 Gateridge Drive, Dallas, TX 75254

Name *
Name
Address *
Address
Phone *
Phone
Would you like to be included on our e-mail list about future events? *
Workshop Attending *
Your guides for this workshops have completed an extensive training process with Dr. Brene’ Brown and her team to understand and teach this curriculum. Your willingness to answer the questions below will help us best assess your readiness for a group experience such as this. Thank you so much for your cooperation in answering these questions: *
Have you ever seen a mental health professional (Psychiatrist, psychologist, marriage and family therapist, social worker, counselor?)
Do you have a therapist you could work with if something came up in this workshop requiring individual/couple attention?
If not, would you like referrals to therapists?
Are you currently taking any medication for mental health issues?