Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Would you like to be included in my e-mail list about future events? *

Yes

No

Workshop Attending *

September Grief Virtual Workshop

September the Art of Play Virtual Workshop

Your willingness to answer the questions below will help me 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?)

Yes

No

Do you have a therapist you could work with if something came up in this workshop requiring individual/couple attention?

Yes

No

If not, would you like referrals to therapists?

Yes

No

Are you currently taking any medication for mental health issues?

Yes

No

By checking the box below you are consenting to have your registration information seen by Sara, Dianne's assistant. All information will remain confidential and will only be used for clerical reasons.

I consent.