Unmasking Shame Registration

Full Name*

First NameLast Name

Phone Number*

Can you receive texts on this phone number? *

YesNo

E-mail*

Confirmation Emailexample@example.com

Location (City/State)*

Street Address

Street Address Line 2

CityState / Province

Country

Can I share your information with other group members?*

Yes! Email, Phone #, and City/StateYes! Email OnlyYes! Phone # OnlyYes! City/State OnlyNo, I will share with the group when I am more comfortable later

Occupation

Birthdate*

MonthDayYear

Martial Status*

Do you have children?*

Yes, and they live with me.Yes, but they don't live with me.No

Briefly describe your life story to date. Share as little or as much background information as you would like. *

Please briefly describe why you are enrolling in intensive. What are your goals or objectives?*

Are you now or have you ever been in counseling or therapy? If yes, please explain.*

Is there anything else you would like to add?

I understand this intensive is faciliated Clinical Mental Health Therapist Janine Deal, but is not a replacement for professional counseling.
I understand Janine Deal and Living on Purpose, LLC holds no responsibility for any harm I may cause to myself or others
I understand Janine Deal may assign homework and failure to complete homework could result in termination of remaining sessions without refund
I understand that if I am unable to complete pre-paid sessions, no refund will be provided. If extenuating circumstances apply, they will be considered on a case by case basis.
I understand that if I miss more than two group sessions without notice, I will forfeit my place in the group without refund.
I understand that a lack of communication with Janine on my part (i.e. not responding to emails and texts and/or not showing up to group sessions) will be interpretted as a withdrawal from group and no refund will be provided.
I understand that each group intensive session will be 90 minutes in length and on a pre-determined date and time. I also understand that being late to a group session will cut into the total session length and will impact other group members' time as well.
I understand that this intensive is confidential and Janine agrees to keep all information strictly confidential, except in situations that violate the law or harm to self or others is disclosed

Choose Intensive Payment Plan*

Weekly Payment Plan$100 due now for Week 1. Then $100 per week for 3 weeks starting Week 2 on October 29, 2024

$100.00

Pay in FullPayment due in full now.

$400.00

Enter coupon

Total

$0.00

Credit Card Details
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Credit Card Number	Security Code
Expiration

Unmasking Shame Intensive

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