Hold Me Tight Registration Form
Name Partner 1
Your answer
Address
Your answer
Phone Number (Best number to reach you in case of a last minute update)
Your answer
Email Address (Best for communication leading up to workshop)
Your answer
Name Partner 2
Your answer
Address (If different then above)
Your answer
Email Address
Your answer
Current relationship status (Please check all that apply)
Required
Number of years together
Your answer
Children, age, living with you?
Your answer
Are you currently or have you even been in couple or individual therapy?
If YES, could you please provide current therapists name (to ensure that therapists and clients to not attend the same workshop)
Your answer
Are either one of you a mental health professional?
Dietary restrictions or concerns?
Your answer
Please describe your relationship (concerns, difficulties, strengths, important or relevant history/events)
Your answer
On a scale of 1-5 please rate your couple distress
What motivated you to register for the weekend and what do you hope to get out of the weekend?
Your answer
Any other details you feel are important for the facilitators to know?
Your answer
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