Family Wellness Roanoke Parenting Workshop Registration Form

Parent Workshop Registration Form

Family Wellness Roanoke is supported by Blue Ridge Behavioral Healthcare, Prevention and Wellness Services, which provides a variety of evidence based programs that are designed to strengthen families by promoting positive family interactions and resiliency. We utilize evidence-based curriculum from the Make Parenting a Pleasure Program that covers ages 0-12 years of age, and these 4 week workshops are offered via Zoom only for residents within the Roanoke Valley of Virginia.
Date
Please note that if you are a parent/caregiver that has an open case with the Department of Social Services, or if you are court ordered to take a parenting class, you must NOT complete this form for the 4 session parent education series, and instead, have your caseworker reach out to Cindy Levasseur at clevasseur@brbh.org to start the referral process.

This 4 week series DOES NOT meet court/CPS/Department of Social Services parent education guidelines, and it is required to take the more intensive 8 week series.
You will receive an email confirmation of this registration form.

If you have Gmail, please be certain to check your email inbox, Promotions folder and spam folder.
What is your preferred language? Zoom will have the ability to live language caption the sessions in your preferred language.*

EnglishSpanish
Survey Question for future planning - Do you prefer to attend a virtual 4 week/once a week 1.5 hour session on:*

Weekdays 8:30am-10:30amWeekdays 6pm-8:00pmSaturday mornings 9am-11amAny of these options is fineNone of these - please feel free to write additional options in the comment section below
Name (Couples MUST register separately)*

First NameLast Name
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How old are your children and do they have medical challenges or special needs diagnoses (We can try and supply additional resources that may be helpful)?*
How did you find out about this parenting workshop series? *
If you are not court ordered to take parenting classes, Please let us know how you found out about our parenting workshops. If someone referred you to us, please write their name or agency name.
Pick series dates*

Notify me via email and/or text message when registration opens for additional dates in 2025.I need an 8 week parenting class series as I am either court ordered/suggested to take one, or have an open case with CPS or DSS. This option meets court/CPS/DSS plan requirements. Please note that you must reach out to your caseworker to start this process, and Family Wellness Roanoke staff cannot due this on your behalf due to privacy laws.Group Workshop request: I would like to discuss setting up a parenting workshop series for a specific group (minimum of 10 participants required)
Please fill out this demographcs form. We utilize this data for grant funding reporting, but the information will remain anonymous. You do have the option to opt out of answering each question.
Gender:*

MaleFemaleGender fluidNon-BinaryTransgenderGender-NeutralUnknownPrefer not to answer
Race:*

WhiteBlackAsianNativeHawaiinOther/UnknownMultiplePrefer not to answer
Ethnicity:*

Non-HispanicHispanicUnknownPrefer not to answer
Age:*

18-2021-2425-4445-6465 Plus
Comments?
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Parent Workshop Registration Form