6 week Co-Parenting Men's class registration Form

6-Week Co-Parenting Women'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
Format: (000) 000-0000.
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?
Is there an active restraining order in your case? (If there is, parent's will be in separate zoom meetings throughout the program.)
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?"
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?
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, 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 and 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 Women's Class Registration Form

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