Workshop Registration

  • All information will be kept confidential.
  • All fields must be completed.
  • After completing this form you will be directed to a page to make payment.
Full Name:  
Email:  
Age:  
Occupation:  
Address:  
City, ST, Zip:     
Country:  
Phone:  

Registration includes single room occupancy room for Friday and Saturday nights and meals starting with Friday lunch and ending with Sunday breakfast. Thursday evening arrival, including dinner Thursday (6:00 PM) and breakfast Friday (7:30 AM), is available for an additional $100. Would you like to arrive Thursday evening?

Are you under treatment for any medical problems?
If yes, please describe:

Please list current medications:

If you are currently in psychotherapy, is your therapist aware of and in agreement with your participation in this workshop?

Are you in recovery from drug or alcohol abuse?
If yes, how long have you been in recovery (we suggest at least one year of recovery before attending this workshop)?

Have you ever been hospitalized for psychiatric reasons?
If so, when?

In case of emergency, please notify:
Name:
Phone:
Relationship:

How did you learn about this workshop?

Please describe why you are attending this workshop and your experiences with loss:

Please let us know if you have any special dietary needs:

Waiver

I understand that my participation in the Moving Through Loss & Transition workshop is voluntary. It may involve my emotions in a manner that could subject me to emotional distress. I agree to accept such risks and assume the responsibility for any effects that may arise from my own interpretation of the process. I understand that this workshop is not intended as psychotherapy or a substitute for psychotherapy. Further, I release Life Transitions Network, and all staff thereof from all claims made by me or on behalf of me (or my estate) by reason of any illness or damages arising from participation in this self-help emotional release process.

I have read, understand and agree to the waiver above (enter your full name as an electronic signature):