Secure Intake Form - Hold Me Tight Couples Workshop Questionaire

Please fill out this questionnaire to express your interest in the workshops. One of our facilitators will contact you to determine whether the workshops are a good fit and will meet your needs.

* = required entry


Demographic Information

* Name:
* Name of Partner
* My partner and I are both committed to attending?  Yes No
Contact Information:

Please provide phone number where we may reach you & leave confidential messages.
* Home #:
Work #:
Cell #:
* Email:
* Full Address:
* How did you find out about this Hold Me Tight workshop?
If it is another professional, please indicate:
Doctor: Therapist: Other:

Workshop Information

* We would like to attend :
The Introductory Workshop – Saturday, April 25th, 2015
The Advanced Workshop – TBD
* Can you describe some of your goals in attending this workshop?
* Are there any concerns you have around physical safety or how you may be feeling that you think we should know about?
Yes No
If Yes, please describe your concern:
* Have you recently been working with a couples therapist?  Yes No
If so, who? Phone #
Are they supportive of you attending this workshop?      Yes No
May we contact your therapist to ensure that this workshop is a good fit for you?  
Yes, my partner and I both consent.


* Do you want to receive information via email about upcoming VCFI Events or Programs? Yes No