Intentional Parenting Support Group Registration
Participant’s Name #1
Name
Date of Birth (DD/MM/YYYY)
Participant's Name #2 (if applicable)
Name
Date of Birth (DD/MM/YYYY)
Youth’s Name (if applicable)
Name
Date of Birth (DD/MM/YYYY)
Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you or your children currently receving services with CTS?
Yes, I am in individual therapy
Yes, my child is in individual therapy
No
Not currently, but was previously
Yes, I have participated in groups
Yes, my child has participated in groups
Other
Have you participated in the Intentional Parenting Workshop (previously called Parenting Orientation)?
Yes
No
A person from our family did, but I did not personally attend
Other
Do you or your child have Medicaid?
Yes
No
Maybe/I'm not sure
What are topics or areas in your relationship with your children you find you need the most help with?
What is your hope in participating in this group?
Private Pay Payment Option
prev
next
( X )
USD
$40 per person, per group meeting
Credit Card
Please sign after reading the acknowledgement above
Continue
Continue
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