Circle of Security Registration Form

Interest Registration Form

PURE HEART THERAPIES
Thank you for completing this interest registration form to attend Circle of Security with Pure Heart Therapies in 2026.

Once you have pressed the submit button below, I will receive an email with your private and confidential information. Within the next few weeks, I will be in contact via email or text to introduce myself and to help answer any questions you may have about the program.

I look forward to connecting with you and it would be my honour to hold this sacred space for you and your family.

Warm Regards,

Sarah Sibi Thomas
Name*

First NameLast Name
Your Phone Number*
Please enter a valid phone number.
Your Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Will your partner be attending the course?*

NoYes, in the same groupYes, in a different group or intake
Would you mind attending a mixed sex group?*

Yes, please place me in a same sex groupNo, I am ok with mixed
Which time would you like to attend Circle of Security commencing on Friday the 6th of February to 27th of March 2026?*

10am-11:30pm AEST12:30-2pm AESTI would prefer to join a group commencing in April 2026
Have you received counselling or group therapy before ?*

YesNo
Do you have any medical or mental health diagnoses? If yes, please specify:*
Do you have faith in Jesus?*

YesNo
Would you like Christian modalities incorporated in the program?*

YesNoI have some questions
What is the main reason you are joining Circle of Security with Pure Heart Therapies?*
How did you hear about Circle of Security through Pure Heart Therapies?*
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Interest Registration Form