6 week Co-Parenting Men's class registration Form

6-Week Co-Parenting Men's Class Registration Form
Please take a moment to provide us with some information about yourself. If you have any questions, please don't hesitate to contact us at (951) 249-3816.
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
How did you hear about us?*
Please Specify
Please indicate how you would like your name printed on your certificate if different than above.
Please provide your co-parent's name below:*
Attorney Information (If applicable):
Are you court-ordered to attend this program?*

YesNo
Is there an active restraining order in your case? (If there is, parent's will be in separate zoom meetings throughout the program.)*

YesNo
Is Child Protective Services (CPS) currently involved in your case? If so, do you authorize us to share updates and a copy of your certificate with your assigned social worker or agency?"*

YesNo
If yes, please enter your social workers name, email and phone number.
How many children do you have and what are their ages?*
Do any of your children have special needs?*

YesNo
Are your children currently receiving counseling, therapy or any mental health treatment?*
What method do you use to communicate with your co-parent? For example, Talking Parents/Our Family Wizard, text, email, Talking Parents /Our Family Wizard app, etc?*
Please provide the terms of your custody agreement. Example: 50/50 shared physical and legal custody.*
What is the biggest issue you are having with your co-parent?*
What would you like to gain from the class?*
PAYMENT

Attention: After submitting your payment, if a blank page appears, please scroll to the top to check for confirmation or check your email for a confirmation message. If you have any questions, feel free to contact us at (951) 249-3816.
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6-Week Co-Parenting Men's Class Registration Form

PAYMENT