Aug-Sept 2024 IFS for Couples

DATES:

Wednesday nights 6:45-8:45pm EST

September 18th
October, 2nd, 9th, 16th, 23rd and 30th

This retreat will facilitate personal growth and emotional development using the Internal Family Systems model through teaching, personal practice, and peer interactions. It is not psychotherapy, nor is it intended to replace psychotherapy, couples therapy, or health care. The exercises you will do in this class may touch deep places inside you that can cause psychological, emotional, physical, or behavioral reactions. For some people, these reactions may be hard to deal with.

IFS is a very safe and respectful form of inner work, but for a few people this retreat may not provide the kind of individual attention and structure needed to feel balanced and safe while working on deep personal issues.

This survey is designed to help us discern together if joining the class will be benificial to you. If we decide you will participate, your answers below will guide me to know how you will have the best experience in this class and give me a sense that you've made an informed decision and are ready for this work.

It is expected that strong emotional content may be shared by other group members during the retreat. This can trigger an emotional reaction in you. The class is not designed to provide extended individual/private support to you. Rather, the group itself will act as a container for our individual responses, to help us regulate ourselves and stay in sync with both our inner experience and the experiences of others around us.

Thank you for your interest in this unique opportunity to learn more about yourself!

**ALL RESPONSES ARE CONFIDENTAL**

Date:*

Date of birth:*

Name:*

Name of partner you are attending with (must register separately):*

Address: Street/PO Box*

City:*

State:*

Zip/Postal Code:*

Cell Phone:*

Email:*

example@example.com

Gender:*

Preferred gender pronouns

Education Background (grade/degree completed, any post secondary):

Current Occupation:*

Are you currently seeing a psychiatrist? If yes, please list the name of the psychiatrist:*

What was the date of your last consultation with your psychiatrist?

Over the last 6 months, on average, how frequently have you had psychotherapy sessions?*

Phone # of your psychiatrist:

If needed, do you give permission to Keith Miller, Calliope Health and Keith Miller Counseling to consult with your psychiatrist or medical doctor about your past and present health and treatment?*

YesNo

Have you met with a psychotherapist for talk therapy within the last year? If yes, please list the name of your therapist:*

What was the date of your last consultation with your psychotherapist?

Phone # of your therapist:

If needed, do you give permission to Keith Miller, Calliope Health and Keith Miller Counseling to consult with your psychotherapist about your past and present treatment?*

YesNo

Children (gender, age)*

Medical Illnesses, Current and Past:*

Have you been prescribed psychiatric medications in the past (e.g. antidepressants, antipsychotics, mood stabilizers, stimulants, tranquilizers)? If so, list each one with dose and describe their effects.*

Have you ever been hospitalized for a psychological difficulty?*

YesNo

Please list dates of psychiatric hospitalizations within the last two years.

Have you ever had feelings or thoughts that you didn't want to live?*

YesNo

Have you attempted suicide?*

YesNo

Are you currently experiencing overwhelming saddness, grief, or depression?*

YesNo

Are you currently experiencing anxiety, or panic attacks?*

YesNo

How many days per week do you drink alcohol?*

How many drinks per day?*

How often do you binge drink (4-5 drinks within 2 hours)?*

How often do you use recreational drugs?*

Have you ever had a dependency on alcohol or recreational drugs?*

YesNo

Has any family member been treated with a psychiatric medication?*

YesNo

In your own words, what is the nature of the concern that you wish to address by participating in this IFS course for couples? Feel free to describe this in as much or as little detail as you wish. What kind of supportive resources or skills do you have that will help you process the emotional content that may emerge during homework or our group experiences? *

Describe the most typical pattern of conflict in your relationship. What happens? What do you do/say? How does your partner respond? What happens next? Describe who you are in conflict, that is, how do you protect yourself and deal with your emotions when you've experienced a disconnect with your partner? *

Describe your experience(s) with couples therapy and how these have been helpful/unhelpful.*

COST:

$599 per couple

REFUND POLICY:

A partial tuition refund of $499 will be given if you withdraw prior to 30 calendar days before the retreat. Tuition is non-refundable inside of 30 days before the retreat.

My Products

6-Week IFS for Couples Zoom Class Product Image

6-Week IFS for Couples Zoom ClassAugust 14-September 18, 2024

$599.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Select one:*

I am making the payment now and my partner knows not to pay when they registerMy partner made the payment and I am registering without payment now.

6-Week Basic IFS Course for Couples

Confidential Information