Please enable JavaScript in your browser to complete this form. – Step 1 of 3Demographic InformationName *FirstMiddleLastDate Of BirthGenderEthnicityRelationship StatusMarriedSingleSeparated DivorcedPartneredDatingWidowedOtherEmployerCurrently EmployedYesNoOccupationHome AddressCityZip Mobile NumberWork NumberWhich phone number is your preferred contact?MobileWorkEmail *Would you like to be notified of future Workshops?YesNoEmergency Contact InformationPlease provide as much information below so i can easily reach your emergency contact if neededName *FirstLastRelationshipMobile Number (copy)Work Number (copy)Referral InformationWere you referred to us?YesNoIf yes, who referred you?If no, how did you hear about us?NextWorkshop InterestPlease answer all of the following questions and indicate if they aren’t applicable to you1. What sparked your interest in participating in this workshop?2. What do you hope to accomplish as a result of your participation in this workshop?3. Have you previously participated in a group?YesNoHow would you respond if someone dominated the discussion?How may you respond if someone never particiapted?PreviousNextPreviousMental Health History With Informed ConsentYour answers to the following questions will help us assess your needs. Please answer to the best of your ability.1. Are you seeing, or have you ever seen a mental health provider?YesNoIf yes, when was that and for what pupose?2. Do you have a therapist that you can work with if something came up that would require attention?YesNoIf not, would you like a referral to a therapist?YesNo3. Are you in recovery from a substance or alcohol abuse? If so, how long have you been sober and what kind of treatment are you receiving at this time?4. Do you have a history of eating disorders or disordered eating? If so, please provide information on the support and treatment that you received.5. Have you experienced distressing life events (i.e., trauma, loss, etc.) that have significantly impacted your ability to function or your quality of life? How have you addressed these issues?PhoneSubmit And Proceed to Paypal