Register Now for the Next Preparing for Takeoff Workshop

Preparing for Takeoff Workshop Registration Form
Join the Virtual 6-Session Super-Parent Preparation Course

Registration Fee: $25 per adult registering

Course Fee: $50 per week for each parent/caretaker, or $285 when paid up front (5% discount)

Next start date is Weds., November 13, 2024, 12-1pm; continues for 6 weeks.
Participant Information
Parent or Caretaker #1*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation
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
Child's Information

Please tell us a little about the child or children you are currently caring for.
Number of Children
Ages of children
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 the child currently in therapy or behavioral programming?

YesNo
Are Parents/Caretakers currently in therapy or behavioral programming?

YesNo
Is the child engaging in any self-harm or suicidal behaviors or behaviors that are dangerous to others?

Yes, currently (in the past 6 months)Yes, in the past (more than 6 months ago)No, never
If yes, please explain
Are you court-mandated for parenting classes? (Please note that this program will NOT fulfill any court mandated requirements and we will not provide documentation for court proceedings regarding your participation in this workshop.)

Yes, I am court mandated AND I understand this course is not considered a fulfillment of my mandated treatmentNo
How did you learn about this virtual workshop?

FacebookInstagramSearch EngineOnline AdsReferralOther
Payment Information
- Session fees may be paid weekly or in one lump sum (Save 5%!).
- 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 since neither you nor your child are a patient of St. Louis DBT and 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 8 sessions up front and save 5% (You will receive an invoice and a payment link about 1 week prior to the start date of class)
Hold my Spot!*
prevnext( X )
Registration FeeThis registration fee secures your spot in the course and does NOT count toward session fees. An invoice will be sent prior to the start date of the course for your session fees. If you have more than 2 people registering, please complete another form.
$25.00 Number of People Registering

Total

$0.00
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 parents participating in this course. This means that I will attend virtually from a non-public 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.
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Preparing for Takeoff Workshop Registration Form

Join the Virtual 6-Session Super-Parent Preparation Course

Participant Information

Second Adult Joining?

Child's Information

Payment Information