Managing Parent-Teen Conflict
This is the registration form to attend our parent-teen (healing relationships, restoring families) class.
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Name of person completing this form: *
Contact phone number *
Email address (enter n/a if you don't have one) *
Agency referral OR self-referral *
Name of agency (if appropriate)
Registering for the class on: *
Conflict is mostly due to : *
LAST Name of Parent *
FIRST Name of Parent *
LAST Name of Other Parent or Caregiver
FIRST Name of Other Parent or Caregiver
First and Last Name of Teen
Telephone number of teen (with parent permission to contact)
Telephone number for parent attending class is: *
Mailing address for parent attending class is: *
Age of Teen / Birth-date
Teen's Gender
Clear selection
Are there other teens in your family who may benefit from this class?
Clear selection
Do you have the capability for remote/ video conferencing ? *
Are you Open to Remote/video Class? *
Can you receive a text message ?
Clear selection
Note: Only individuals named on this referral can attend the class.
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This form was created inside of Mediation Center of the Coastal Empire. Report Abuse