Living with Rigidity Workshop Registration Form

Living with Rigidity Workshop Registration Form
Join the Virtual 6-Session Educational and Supportive Workshop

Registration Fee: $25 per adult registering

Course Fee: $50/session for each participant ($300 total session fees)
Virtual Workshop Schedule:

Tuesdays, 5:30pm - 6:30pm CST

Starting September 3, 2024

Continues for 6 weeks
Participant Information
Participant #1*

First NameLast Name
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to person with Overcontrolled Coping:
Optional / Current or Previous
Second Adult Joining?

Please share their contact information below.
Additional Adult Name

First NameLast Name
Additional Adult Phone Number
Please enter a valid phone number.
Additional Adult Email
example@example.com
Relationship to person with Overcontolled Coping:
Optional / Current or Previous
More than 2 adults? Please provide names, emails, and relationship below:
Please tell us about some of the problems you have been struggling with. This information will help us tailor our curriculum to meet your needs.
Is your loved one currently in therapy or behavioral programming?

YesNoNot Sure
Are you currently in therapy or behavioral programming?

YesNoNo Answer
How did you learn about this virtual workshop?

FacebookInstagramSearch EngineOnline AdsReferralOther
Payment Information
- Session fees may be paid weekly or in one lump sum.
- Full payment for all 6 sessions is required even if all sessions are not attended.
- Participants may request missed information or handouts from the class facilitator
PLEASE NOTE: This is a workshop and not a clinical service. Therefore, it is not reimburseable by insurance. You may use your HSA account to pay for it and you may request a statement for tax purposes, but because this is an educational, not a clinical service meant to diagnose or treat a condition, your insurance will not view it as a covered service.*

I understand
Please choose how you would like to be charged:*

I would like to pay weekly (You will not pay the full fee today, but you will be asked to provide your credit card information later via a secured platform, TheraNest, and it will be charged weekly)I would like to pay for all 6 sessions up front. (You will receive an invoice and a payment link prior to the start date of class)
My Products*
prevnext( X )
Registration FeeHold my spot! This non-refundable fee holds your spot in this class.
$25.00 Quantity
By signing below, I agree to the following course requirements:
- In order to facilitate a safe space in which to share and learn, I agree to keep confidential anything disclosed by other people participating in this course. This means that I will attend virtually from a private location and use headphones if others are within listening range.
- I understand that the instructor of this course is a mandated reporter, so statements that indicate abuse of a child may be reported according to state and federal law.
- I agree to attend as many sessions as I am able to and understand that my participation adds to the experience of all.
- If I am unable to attend a session, I will contact the instructor ahead of time to let them know.
- I understand that I am still responsible for payment for a missed session and that I may request materials from the session.
- I understand that this course does not consititute a clinical service, is not meant to diagnose or treat a condition, and is not reimburseable by my insurance, but may qualify for payment using an HSA.
Signature

Powered by Jotform SignClear
Should be Empty:

Living with Rigidity Workshop Registration Form

Join the Virtual 6-Session Educational and Supportive Workshop

Virtual Workshop Schedule:

Participant Information

Second Adult Joining?

Payment Information