NutureHer Cohort Application

NUTUREHER COHORT APPLICATION

Thank you for your interest in NurtureHer. This brief application helps ensure the cohort is a supportive and aligned fit. There are no “right” answers, only honest ones. Applications are reviewed with care.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Cellular Number*
Format: (000) 000-0000.
If you were referred to the group, please provide the name of your referral.
Age(s) of Your Daughter(s)*
NutureHer Cohort meets on Saturday mornings from 9A-10:30A, for 8 consecutive weeks. Are you able to attend those sessions at the scheduled time?*

YesNo
What drew you to the NurtureHer cohort?*
When conflict or tension arises with your daughter, what do you notice happening inside you (emotionally, physically, or relationally)?*
Are there patterns from your own upbringing or early relationships that you are becoming more aware of in your parenting? If so, briefly describe.*
What are you hoping will be different for you by the end of the 8 week cohort?*
Please review each statement and indicate your agreement.
I understand that NurtureHer focuses on my own healing, health and growth as a mother, not fixing or treating my child.*

I agree and understandI disagree
I am willing to engage in both, psycho-education and facilitated group processing, including personal reflection and sharing as I feel comfortable.*

I agree and understandI disagree
I understand that this is a closed cohort and that consistent attendance supports emotional safety for the group.*

I agree and understandI disagree
I understand that NutureHer is not family therapy, crisis intervention, or a substitute for individual therapy when higher levels of care are needed.*

I agree and understandI disagree
Are you currently experiencing an active mental health crisis or safety concern (i.e., suicidal thoughts, active domestic violence, severe instability)?*

YesNo
Are you currently engaged in individual therapy?*

YesNo
The investment for the NutureHer cohort is $895 OR pay what you can. The heart of this group is to provide safety, community and healing. If you have the ability to pay the full fee, it is much appreciated and will be used to fund the group. If you cannot make the full payment, any payment and investment is appreciated! No matter what you pay, all group members will receive the same materials and experience.*

I understandI disagree
If accepted, are you open to a brief 10-15 minute consultation to confirm fit and review next steps?*

YesNo
Is there anything else you would like me to know as applications are reviewed?*
Signature*
Date of Signature*

MonthDayYear
Date
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NUTUREHER COHORT APPLICATION