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

This workshop involves couples working independently on exercises with each other.
* My partner and I are both committed to participating together?  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 :
Spring – Saturday March 5th, 2016 & Saturday April 2nd, 2016
Fall – Saturday October 15th, 2016 & Saturday November 19th, 2016
For therapists and their partners – Saturday January 7th, 2017 & Saturday January 21st, 2017
* 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
In some cases we find it helpful to speak with your couple's therapist. May we have your permission to do so?  
Yes, my partner and I both consent.


* How would you like to pay?
PayPal Cheque
* Do you want to receive information via email about upcoming VCFI Events or Programs? Yes No