Clone of Emotion Coach Study Group Registration Form

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
How did you hear about the Lessons in Love for Singles Workshop?* This field is required.Social media, website, friend, etc.
4
Workshop Expectations* This field is required.What do you hope to get out of the Gottman Lessons in Love for Singles workshop?
5
Every participant is required to purchase their own Lessons in Love Singles Guide from the Gottman Institute to participate in the workshop* This field is required.https://www.gottman.com/product/lessons-in-love-digital-singles-guide/
I have the Lessons in Love Singles Guide
6
The study group is offered to Quebec residents only (with exceptions prior approved by facilitator)* This field is required.
I am a Quebec resident
I am not a Quebec resident but I have been approved to join by facilitator
7
This workshop is appropriate for singles, divorced, individuals who are at the early phase of dating who are seeking a fulfilling, monogamous relationship.* This field is required.Participant
I am single seeking a fulfilling monogamous relationship
8
The workshop is not appropriate for individuals with severe distress, significant emotional or physical abuse, serious emotional or mental health problems, individuals who are actively addicted to drugs or alcohol, and people who have serious compulsive behaviour with gambling, sexual acting out, and other disruptive behaviours.* This field is required.Workshop Disclaimer
I am not experiencing severe emotional distress
I do not have an active addiction
9
It is not a therapy group and does not provide psychological treatment, diagnosis, or individualized advice, and participation does not establish a therapist-client relationship. Parents are encouraged to seek professional support for concerns beyond the scope of this group.* This field is required.Study Group Disclaimer
I understand this is not a therapy group
10
To ensure an effective workshop for all participants, we ask all participants to be respectful and kind during the workshop.* This field is required.
I agree to be respectful and kind during the workshop
11
Today's Date* This field is required.
Date
Month
Day
Year
12
The registration fee for the 4 hour workshop is $100* This field is required.One of our organization’s missions is to foster a community of parents becoming Emotion Coaches together. If you are interested in supporting this mission financially, we welcome donations through our website.
I understand and agree to proceed to payment
13
Emotion Coaching Study Group Registration* This field is required.
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costCAD
Lessons of Love for Singles Gottman Workshop
$100.00CADEdit
Back
Total cost $0.00CAD
Credit Card
First Name
Last Name
Should be Empty: